Splenic Injuries
Injuries to the spleen are often caused by direct trauma to the left lower chest wall or left upper abdominal quadrant. Initial presentation may include fainting, dizziness, and weakness from blood loss, but is often limited to left upper quadrant pain with or without left shoulder pain (Kehr's sign). A mass in the left upper quadrant, abdominal distension, and abdominal stiffness were also common on physical examination. Ballone's sign (fixed dullness on the left flank and dullness changing position on the right flank) has been described as a rare finding. The spleen capsule may contain bleeding, and physical examination results are sometimes delayed in presentation. Late spleen rupture is a rare complication of splenic injury20 but a major treatment concern.
Standard radiographs may show an enlarged spleen if there is a subcapsular hematoma with an intact capsule. An enlarged spleen can also move the stomach anteriorly and the left kidney, left transverse colon, and splenic flexure downward. On radiography, turbidity of the abdomen,
The bulging flanks and loops of the small intestine are associated with signs of free peritoneal fluid, such as blood. The use of ultrasound to diagnose splenic injuries is common, and the sensitivity to diagnose splenic injuries is greater than for other abdominal organs. However, the appearance of the spleen on ultrasound scans can vary greatly. Siniluoto et al. has shown that repeated ultrasound evaluation will eventually detect splenic lesions if the exam is performed for 1-3 days. Many trauma centers use ultrasound as a screening test because it can be done quickly and
Targeted examination can be performed as a low-cost method of classifying patients with blunt abdominal trauma. Some authors use ultrasound to monitor patients due to their low cost and lack of ionizing radiation. The "gold standard" test for evaluating a spleen injury is computed tomography (CT). CT scan results include capsular abnormalities,
subcapsular and intrasplenic hematomas, single and multiple fractures and shattered and fragmented spleens. The sensitivity and specificity of computed tomography in the diagnosis of splenic injury are generally in the 96% range.
Buntain’s Classification of Splenic Injury
■ Grade I: Localized capsular disruption or subcapsular
hematoma without significant parenchymal injury
■ Grade II: Single or multiple capsular and parenchymal
disruptions that do not extend into hilum or involve major vessels
■ Grade III: Deep fractures, single or multiple, extending into
the hilum and involving major blood vessels
■ Grade IV: Completely shattered or fragmented spleen or separated
from its normal blood supply at the pedicle required
for radiologic healing and return to activity. The American Association for the Surgery of
Trauma (AAST) classification
has been shown to correlate with an increased
risk
for operative management. The majority of injuries to the spleen can be treated
nonoperatively, with more than half of the higher-grade injuries managed
nonoperatively. However, patients who do not stabilize with minimal
resuscitation, those with recurrent hemodynamic instability, and
those
with the presence of pooling or “blush” in the spleen on the initial CT scan
with intravenous contrast all predict the failure of nonoperative management. On
the field, the athletic trainer should obtain baseline vital signs, perform an
abdominal examination, reassess vital signs for evidence of vascular instability,
and decide if triage to the emergency room is required. If vital signs appear
stable and abdominal pain does not increase with cough, sneeze, or rapid
movements (all seen with peritoneal irritation), observation is a reasonable
option. If there is any evidence of vascular
instability,
transport should be considered. Placement of an IV for fluid challenge if a question
of vascular instability is present should be considered only when
transportation to a hospital cannot be easily accomplished.
Injuries to the spleen are most often caused by direct trauma to the left lower chest wall or left upper abdominal quadrant. The initial presentation may include fainting, dizziness, and weakness from blood loss but often is confined to left upper quadrant tenderness with or without left shoulder pain (Kehr’s sign). A left upper quadrant mass, abdominal distension, and abdominal rigidity are also frequent physical examination findings. Ballone sign—fixed dullness in the left flank and shifting position dullness in the right flank—has been described as an infrequent finding. The capsule of the spleen can contain bleeding, and physical examination findings are occasionally delayed in their presentation. Delayed rupture of the spleen is an uncommon complication of splenic injury20 but an important concern in management.
Plain
x-rays may demonstrate an enlarged spleen if a subcapsular hematoma with an
intact capsule is present. An enlarged spleen may also displace the stomach
anteromedially and the left kidney, left transverse colon, and splenic flexure
inferiorly. On x-ray, haziness of the abdomen,
bulging
flanks, and displacement of small bowel loops are associated with signs of free
peritoneal fluid, such as blood. Use of ultrasound to diagnose splenic injuries
is common, and sensitivity in diagnosing splenic injuries is greater than for
other abdominal organs. However, the appearance of the spleen on sonograms can
vary widely. Siniluoto et al. demonstrated that repeat ultrasound evaluation
will ultimately pick up splenic injuries if the examination is followed for 1
to 3 days. Many trauma centers use ultrasound as a screening test because it
can be performed rapidly, and a
focused
examination can be performed as a low-cost method for triaging patients with
blunt abdominal trauma. Some authors use ultrasound to follow patients because
of its low cost and lack of ionizing radiation. The “gold standard” test to
evaluate an injury to the spleen is computed tomography (CT) scanning. Findings
on CT scan include capsular disruptions,
subcapsular
and intrasplenic hematomas, single and multiple fractures, and shattered and
fragmented spleens. Sensitivity and specificity of CT scan in the diagnosis of
splenic injury are generally in the range of 96%.
Buntain’s Classification of Splenic Injury
■ Grade I: Localized capsular disruption or subcapsular
hematoma without significant parenchymal injury
■ Grade II: Single or multiple capsular and parenchymal
disruptions that do not extend into hilum or involve major vessels
■ Grade III: Deep fractures, single or multiple, extending into
the hilum and involving major blood vessels
■ Grade IV: Completely shattered or fragmented spleen or separated
from its normal blood supply at the pedicle required
for radiologic healing and return to activity. The American Association for the Surgery of
Trauma (AAST) classification
has been shown to correlate with an increased
risk
for operative management. The majority of injuries to the spleen can be treated
nonoperatively, with more than half of the higher-grade injuries managed
nonoperatively. However, patients who do not stabilize with minimal
resuscitation, those with recurrent hemodynamic instability, and
those
with the presence of pooling or “blush” in the spleen on the initial CT scan
with intravenous contrast all predict the failure of nonoperative management. On
the field, the athletic trainer should obtain baseline vital signs, perform an
abdominal examination, reassess vital signs for evidence of vascular instability,
and decide if triage to the emergency room is required. If vital signs appear
stable and abdominal pain does not increase with cough, sneeze, or rapid
movements (all seen with peritoneal irritation), observation is a reasonable
option. If there is any evidence of vascular
instability,
transport should be considered. Placement of an IV for fluid challenge if a question
of vascular instability is present should be considered only when
transportation to a hospital cannot be easily accomplished.
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