What is Splenic Trauma (Spleen Injury)?
Injuries to the spleen can be either due to sharp objects piercing the skin or a result of blunt force. There are ways to classify these injuries depending on how serious they are and the part of the spleen that is affected. In recent years, doctors often manage these injuries without needing to perform surgery. However, patients who have had their spleen removed face significant challenges related to their immune system. These challenges need to be handled appropriately, particularly when there is an infection.
What Causes Splenic Trauma (Spleen Injury)?
Splenic trauma, or injuries to the spleen, can be either penetrating or blunt. In children, it is crucial to consider non-accidental trauma when investigating spleen injuries. A pre-existing condition known as splenomegaly, which makes the spleen larger than normal, can weaken the spleen’s outer layer and make it more prone to injuries.
The lower part of the spleen, which is less shielded by the ribs, may be more easily injured. In the United States, the most common cause of spleen injuries is blunt trauma, often resulting from car accidents.
Spleen injuries can also be caused by penetrating trauma, resulting from either intentional or accidental incidents. Interestingly, in the case of a penetrating injury, even a very small wound can cause serious damage to the spleen.
Risk Factors and Frequency for Splenic Trauma (Spleen Injury)
The spleen is often cited as the organ that gets injured most often in both blunt and sharp force injuries. It’s important to note that a wound doesn’t need to be close to the spleen to cause serious damage. Interestingly, stab wounds inflicted by someone who is right-handed often enter the abdomen on the left side, leading to more incidents of spleen injuries compared to injuries caused by left-handed individuals. Also, because spleen injuries can occur with other severe injuries, it’s crucial to check for these during patient evaluation.
Signs and Symptoms of Splenic Trauma (Spleen Injury)
Injury to the spleen should be suspected if a person has a history of trauma or harm to the left upper abdominal area. This could be indicated by Kehr sign, which is pain in the left shoulder that gets worse when a person inhales deeply. Common signs of a spleen injury include tenderness in the stomach and abdominal wall bruises or swelling. Sometimes, there might also be a noticeable increase in the size of the spleen (splenomegaly). However, even if none of these signs are present, a spleen injury shouldn’t be ruled out if the individual has a history or symptoms that indicate possible harm to the spleen.
Testing for Splenic Trauma (Spleen Injury)
When a patient is unsteady due to a critical condition such as severe injury or bleeding, a medical test known as the FAST exam is used to quickly evaluate the degree of trauma and bleeding. If a person is suspected to have injury inside the abdomen, the usual approach is to follow the FAST exam with a CT scan, in places where the facility is available and if there are no other urgent matters.
In regions or cases where a CT scan can’t be done in a timely manner, like in certain parts of the developing world, another procedure called diagnostic peritoneal lavage (DPL) can be considered. A CT scan is typically used to assess the extent of injury, traditionally using oral or intravenous (IV) contrast (a type of dye). However, more recently, there’s been a shift towards considering that the consumption of contrast might not be necessary for analyzing trauma patients with suspected injuries inside the abdomen.
When a remedy or dye called IV contrast is not used, it’s important to understand that the CT images of the spleen can be different and that serious injuries to the spleen could go unnoticed due to less than ideal imaging. Findings from the CT scan can include blood in the abdominal cavity and shades of brightness indicating dye leakage. But these signs may not be seen if enough dye hasn’t been used to enhance the images of the spleen.
Monitoring vital signs is important to keep track of the patient’s stability. Stable patients don’t need repeated CT scans. However, if the patient’s condition changes, additional tests might be necessary. Other imaging tests like plain films and MRI have limited usefulness and typically aren’t used to evaluate spleen injuries.
Treatment Options for Splenic Trauma (Spleen Injury)
If a patient suffering from trauma is stable, medical professionals typically prefer treatments that don’t involve surgery. These methods could include giving fluids or replacing blood as needed and monitoring the patient’s condition. However, if a patient is unstable, has suffered a significant injury elsewhere in the body, or is currently taking blood thinners, they might need surgery.
During the surgery, known as an exploratory laparotomy, doctors can look inside the body, repair damage, or remove injured tissues or organs. If noninvasive treatments fail, something called angiographic embolization might be used instead of surgery. This is a procedure where a doctor uses a catheter to release small particles into a blood vessel to stop blood flow to a certain area.
What else can Splenic Trauma (Spleen Injury) be?
Detecting a hurt spleen in a patient with unspecified abdominal injuries has become more accurate over the years owing to significant improvements in advanced imaging. Depending on the severity, injuries to the spleen either need surgery or they don’t. If the spleen is bleeding uncontrollably, immediate surgery is more probable. On the other hand, if the bleeding is confined within an intact spleen, the patient might not need surgery.
One method for determining whether the patient needs surgery is diagnostic peritoneal lavage (DPL). This is a medical procedure usually performed to determine whether abdominal bleeding is serious enough to require surgery. However, it is now of historical interest only and is used in places where advanced imaging isn’t available or it takes too long to perform.
Nowadays, point of care ultrasound (POCUS) is more commonly used. The specifics of the POCUS method, named FAST (focused assessment with sonography for trauma), are detailed elsewhere. According to the FAST rule, if there is free fluid in the abdomen, it’s suggestive of hemorrhaging and the patient might need surgery. However, neither DPL nor FAST can identify the source of bleeding. This is left for the surgeon to determine during the surgery itself.
A negative FAST exam result indicates that it’s safe to undergo more advanced imaging like a CT scan to further examine the condition of the spleen. CT scans are believed to provide a much more precise understanding of spleen injuries, especially when a special dye (contrast) is used to improve the visibility of internal bodily structures. These images are then used to plan the best treatment for the specific type of spleen injury.
What to expect with Splenic Trauma (Spleen Injury)
When someone has a spleen injury, time plays a crucial role in their initial assessment and treatment. This is because whether they get surgery or endovascular treatment quickly can affect the injury’s outcome, particularly for serious spleen injuries. If there are delays in their treatment, they might lose a lot of abdominal blood. Whenever possible, doctors try to save the spleen because it is important for a strong immune system.
As per some research, major medical centers with a wide range of services are more likely to save the spleen. However, if someone gets injured in a remote area with limited medical facilities, it might be best to have surgery performed by a general surgeon in the nearest functioning operating room. This is because long transport times can result in excessive blood loss and worsen the prognosis.
There’s a theory that, if a long delay in comprehensive treatment is unavoidable, postponing surgery might not be more advantageous than managing without surgery. However, this idea probably needs more evidence before any concrete conclusions are made about delaying treatment for spleen injuries in resource-limited settings.
In the past, patients who had their spleens removed were at high risk of serious infections. Thankfully, vaccinations against S. pneumoniae, H. influenzae, and N. meningitidis have largely reduced this risk. However, vaccine coverage varies across populations, which also results in differences in predicted infection risks in patients who’ve had their spleens removed.
Preventing Splenic Trauma (Spleen Injury)
Injury prevention, especially in patients who have already suffered trauma, is a key focus for those in charge of trauma care. In developed countries, some experts believe that enhancing our infrastructure and educating the general public could help save numerous lives. As of 2019, there has been growing interest in the United States about potentially imposing stricter controls on gun ownership as one way to prevent injuries. However, this issue has become deeply politicized, sparking intense and often heated discussions.
