injuries poisoning
Splenic Injury
Treatment of Splenic Injury
Observation Angioembolization Sometimes surgical repair or splenectomy In the past, treatment for any splenic injury was splenectomy. However, splenectomy should be avoided if possible, particularly in older patients, children, and patients with hematologic malignancy, to avoid the resulting permanent susceptibility to bacterial infections, increasing the risk of overwhelming postsplenectomy sepsis. The most common pathogen isStreptococcus pneumoniae, but other encapsulated bacteria such asNeisseriaandHaemophilusspecies may also be involved. Currently, most low-grade and many high-grade splenic injuries can be managed nonoperatively, even in patients > 55 years. Hemodynamically stable patients who have no other indications for laparotomy (eg, hollow viscus perforation) can be observed with monitoring of vital signs and serial abdominal examinations and hematocrit (Hct) levels. Need for transfusion is compatible with nonoperative management, particularly when there are other associated injuries (eg, Femoral Shaft Fractures ). However, there should be a predetermined transfusion threshold (typically 2 units for isolated splenic injuries) beyond which surgery should be done to prevent morbidity and mortality. In one high-volume trauma center, of those who fail nonoperative management, 75% fail within 2 days, 88% within 5 days, and 93% within 7 days of injury ( Similar to Hepatic Injury , there is no consensus in the literature regarding duration of restricted activity, optimum length of stay in the intensive care unit (ICU) or hospital, timing of resumption of diet, or need for repeat imaging for splenic injuries managed nonoperatively. However, the more severe the injury, the more care should be taken before permitting resumption of activities that may involve heavy lifting, contact sports, or torso trauma. Patients with significant ongoing hemorrhage (ie, significant ongoing transfusion requirements and/or declining hematocrit [Hct]) require laparotomy. Sometimes when patients are hemodynamically stable, angiography with selective embolization of bleeding vessels is done. When surgery is needed, hemorrhage can sometimes be controlled by suturing, topical hemostatic agents (eg, oxidized cellulose,thrombincompounds, fibrin glue), or partial splenectomy, but splenectomy is still sometimes necessary. Splenectomized patients should receive thepneumococcal vaccine; many clinicians also vaccinate againstNeisseriaandHaemophilusspecies. Stassen NA, Bhullar I, Cheng JD: Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg73:S288-S293, 2012. doi: 10.1097/TA.0b013e318270160d 