Splenic Injury
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| some functions of the spleen are: | removal of unwanted elements from blood, secondary organ of the immune system, source of hematopoietic cells, sequestration of a portion of the formed blood elements.
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| This is an intra-abdominal organ frequently injured in blunt trauma | spleen
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| ninety percent of cases of injury to the spleen results from this mechanism | blunt trauma
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| patients with injury to the spleen from blunt trauma should be managed on the basis of... | their hemodynamic status
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| this hemodynamic status describes the patient as never hypotensive or tachycardic | hemodynamically stable
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| this hemodynamic status describes the patient as having tachycardia/hypotensive but they resolve with fluid resuscitation | responsive
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| this hemodynamic status describes a patient as unstable, and these patients do not respond to volume repletion | unstable
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| are history and physical exam sensitive or specific for diagnosing splenic injury? | no
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| findings that raise suspicion for splenic injury: | generalized abdominal pain, pain that localizes to the left upper quadrant, pain in the left shoulder (due to subdiaphragmatic blood-positive Kehrs sign), lower left rib (9-12) fractures,
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| these are needed to diagnose splenic injury in a hemodynamically stable patient: | history and physical exam, ultrasound which may reveal free intra-abdominal fluid, CT scan: IV contrast is used to evaluate for extravasation of contrast outside the splenic vessels and spleen itself.
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| "contrast blush" on a ct scan suggests what? | ongoing bleeding and is considered by some indication for operative intervention.
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| does free fluid in the abdomen via FAST exam confirm presence of splenic injury? | no
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| what does FAST stand for? | focused assessment for the sonographic evaluation of the trauma patient. it is an ultrasound examination that can quickly and fairly accurately assess for free fluid. evaluates morison's pouch, splenorenal recess, pelvis, pericardium
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| is the FAST test diagnostic of injury to any specific organ? | no
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| what is Morison's pouch? | the potential space that separates the liver from the right kidney
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| This method is used to diagnose splenic injury in the unstable patient. You insert a catheter through a small supra or infra umbillical incision. peritoneal contents are aspirated and examined. | peritoneal lavage. this method takes a long time
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| a positive diagnostic peritoneal lavage is indicative of what? | laprotomy
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| what are the criteria for nonoperative management of blunt splenic injury? | hemodynamic stability, no indication for laprotomy on the basis of physical exam findings or diagnostic tests, no transfusion requirement attributed to splenic injury, constant availability of surgical and critical care resources
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| what are the criteria for failure of nonoperative manage of a blunt splenic injury? | increasing or persistent fluid requirements to maintain normal hemodynamic status, peritoneal signs of rebound tenderness, transfusion requirements to maintain hematocrit hemodynamic stability, failed angioembolism of arteriovenous fistula/pseudyaneurysm
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| for nonoperative management of splenic injury to be considered you need the following: | hemodynamically stable patient, constant availability of ICU, surgeon, OR staff, serial abdominal examinations, serial H/H monitoring, repeat CT scans in most cases.
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| what are two important points to consider for management of splenic injury? | grade of injury, age of the patient.
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| what is the single worse sequelae/ clinical manifestation? | increased susceptibility to disseminated infection with encapsulated bacteria.
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| what three types of encapsulated bacteria are the most common cause of infection in post-splenectomy patients? | strep pneumoniae, hemophilus influenza, neisseria meningitidis
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| this describes a sudden onset of symptoms with rapid and fulminating course that often last only 12-18 hours. patients complain of fever, nausea, vomitting, headache, and altered mental status. infection may occur at any time after splenectomy. | overwhelming postsplenectomy infection
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| what is the most common organism responsible for post splenectomy infection/ | strep pneumoniae
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| what are some prophylactic treatments for splenectomized patients? | polyvalent pneumococcal vaccine (pneumovax) which protects against strep pneumoniae. HIB conjugate is also given, as well as meningococcal polysaccharide (Menactra)
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