![]() Splenic trauma must be discovered in the undifferentiated abdominal trauma patient. Plain films and MRI offer limited value and are not indicated for the evaluation of splenic trauma. Follow-up studies are indicated as needed for patients whose clinical status changes. Repeat CT scans are not indicated in hemodynamically stable patients. Assessment of vital signs is imperative to monitor hemodynamic status. Contrast blush and extravasation are predicted to fail to appear in the absence of adequate IV contrast enhancement of the spleen images. CT findings may include hemoperitoneum, hypodensity, and contrast blush or extravasation. If IV contrast is not used (as of 2017), it is understood that even with modern multi-detector CT scanning, very significant splenic injuries could be missed by the lack of image optimization. The IV contrasted spleen is significantly different in appearance on CT than similar images obtained without IV contrast. CT scan of the abdomen has traditionally been performed with oral and/or intravenous (IV) contrast to assess the degree of injury, although there has been a recent movement toward consideration of ingested contrast as no longer mandatory in the CT scanning of trauma patients with suspected intraabdominal injuries. Where a CT scan is unavailable in a reasonable timeframe, such as in some areas in the developing world or similar settings, diagnostic peritoneal lavage (DPL) can be considered as the next step after negative FAST. ![]() It is understood in the developed world that a CT scan will follow a negative FAST evaluation of a trauma patient with a suspicion of intraabdominal trauma unless other operative or management priorities must be addressed first. The persistence of an unimmunized minority in developed nations despite the near-unanimous recommendations of the medical community for the immunization of children will likely prevent changes in this recommendation for the foreseeable future.Ī FAST exam should be used in hemodynamically unstable patients to assess the degree of trauma and bleeding rapidly. The vast majority of children in developed nations (as of 2017) receive a series of polyvalent anti-streptococcal vaccinations, but to date, this has not changed the post-splenectomy vaccination recommendation. Infectious disease issues affecting trauma patients in the developing world and of completely unimmunized patients are discussed elsewhere. As of 2017, a 13-valent anti-streptococcal vaccination has become available in some markets. Anti-streptococcal vaccination is evolving, and polyvalent vaccines are becoming more used and, over time, have been developed against a wider spectrum of subspecies. Fortunately, as of the 2010s in the developed world, there are effective vaccines for the latter two, which are usually given to children prior to entering elementary school ( H. Historically, the most feared organisms in this setting have been Streptococcus, Neisseria meningitis, and Haemophilus influenzae type B. Antipneumococcal vaccination is typically given around 2 to 3 weeks after splenectomy to decrease the risk of catastrophic sepsis events. To reduce potential care delays, the emergency care provider is advised to clarify ahead of time if there are any age cutoffs for trauma patient management in general and spleen injury cases in particular at their specific facility. Pediatric spleen trauma management is similar to that in adults. ![]() The role of antihemorrhagic intravenous agents such as tranexamic acid is discussed elsewhere. These grades often guide treatment decisions, such as if observational or operative management is chosen for the spleen injury by the treating surgeon. Grade 5 is either a shattered spleen or complete devascularization of the entire spleen. Grade 4 is a laceration involving a hilar or segmental blood vessel if there is partial devascularization or if it is more than 25% of the spleen. Grade 3 is hematoma of more than 50% of the subcapsular surface area or if the hematoma is known to be expanding over time, if the hematoma has ruptured, intraparenchymal hematoma either more than 5 cm or known to be expanding, or capsule laceration more than 3 cm in depth and/or involving a trabecular blood vessel. Grade 2 is hematoma 10 to 50% of surface or capsule laceration 1 to 3 cm in depth. Grade 1 is less than 10% of surface area involved in hematoma or capsule laceration less than 1 cm. Spleen trauma is graded from 1 to 5 in increasing order of severity.
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