BLUNT SPLEEN MANAGEMENT PROTOCOL 2011

A. NOTS Blunt Spleen Management Protocol B. All adult patients with an identified blunt spleen injury (> 14 years of age) C. Prehospitital Recommendations: Follow NOTS triage protocols

D. E.D. Recommendations Ensure 2 good working IVS Unstable patients with known spleen injuries or positive FAST: Should go to OR ASAP, providing cause of hemodynamic instability is related to their abdominal trauma Stable Patients: Abdominal/Pelvis CT indicated for any suspected abdominal injuries -CT with IV contrast is study of choice to make diagnosis If spleen injury is identified at a NON-Trauma Hospital arrange for Transfer – Call Trauma Transfer Center (FCO)

E. Initial Treatment Recommendations Treat other identified injuries as indicated Grade I and II injuries – admit for minimum of > 24 hours with serial exams and HCTs Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6 hrs) for a minimum of 3 times and until stable Grade III injuries with moderate to large hemoperitoneum – Splenic Artery Angio-embolization (SAE) within 2 hours

E. Initial Treatment Recommendations Treat other identified injuries as indicated Grade I and II injuries – admit for minimum of > 24 hours with serial exams and HCTs Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6 hrs) for a minimum of 3 times and until stable Grade III injuries with moderate to large hemoperitoneum – Moderate to Large Peritoneum: defined fluid seen in a least Splenic Artery Angio-embolization (SAE) ASAP with goal to be within 2 hours

E. Initial Treatment Recommendations Treat other identified injuries as indicated Grade I and II injuries – admit for minimum of > 24 hours with serial exams and HCTs Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6 hrs) for a minimum of 3 times and until stable Grade III injuries with moderate to large hemoperitoneum -Splenic Artery Angio-embolization (SAE) ASAP with goal to be within 2 hours Grade IV injuries: SAE ASAP with goal to be within 2 hours Grade V injuries: to OR in most circumstances Grades I – IV: that show CT evidence of blush/pseudoaneurysm or extravasation - SAE ASAP with goal to be within 2 hours

F. In-Hospital Recommendations Patients should be NPO and on bed rest until HCT stable Grade 1 and 2: minimum of 1 floor day and 2 total hospital days Grade 3-5: minimum of 3 hospital days Splenectomy patients require immunizations prior to DC from the hospital H. flu Meningococcus Pneumococcus

F. In-Hospital Recommendations DVT prophylaxis SCDS upon admission Stable HCT for 48 - 72 hours and no other contraindications- Strongly consider starting chemoprophylaxis until DC (Low molecular weight heparin is preferred)

G. Post Discharge Recommendations Documentation that patient was seen in “Trauma Clinic” 1– 4 weeks post discharge Documentation in the chart of when and if the patient as can return to Normal Activity Documentation of need for flu shot and education regarding infections and splenectomy

Moderate/Large hemoperitoneum Initial Mangement of a Hemodymically Stable Patient with a Blunt Spleen Injury CT scan with IV contrast Grade V Blush, Extravisation, or Psuedoaneurysm Grade I & II can admit to Floor Grade III Grade IV No or Small hemoperitoneum Moderate/Large hemoperitoneum Angio-Embolization (within 1-2 hours) Floor patients: should be mobilized, diet advance and daily HCTs until stable for two days. Grade 1 and 2: minimum of 1 floor day Grade 3-5: minimum of 3 hospital days Splenectomy patients require immunizations ICU/Step-down unit* - q 4- 6 hr HCTs until stable X 3 Stable HCTs for 24 hours Dropping HCTs for 24 hours, or need to transfuse blood Consider the following options: OR, angio, Repeat CT scan Can mobilize patient, transfer to floor, and give diet pending other injuries

References 1. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. J Trauma. 2009 Sep;67(3):565-72; discussion 571-2.PMID: 19741401 [ 2. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, Root HD, Pruitt BA Jr, Strodel WE. J Trauma. 2000 May;48(5):801-5; discussion 805-6.PMID: 10823522 [PubMed - 3. Improved outcome of adult blunt splenic injury: a cohort analysis. Rajani RR, Claridge JA, Yowler CJ, Patrick P, Wiant A, Summers JI, McDonald AA, Como JJ, Malangoni MA. Surgery. 2006 Oct;140(4):625-31; discussion 631-2.PMID: 17011910 4. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G, Kudsk KA, Pritchard FE. J Trauma. 1998 Jun;44(6):1008-13; discussion 1013-5.PMID: 9637156 5. Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury. Liu PP, Lee WC, Cheng YF, Hsieh PM, Hsieh YM, Tan BL, Chen FC, Huang TC, Tung CC. J Trauma. 2004 Apr;56(4):768-72; discussion 773.PMID: 15187739 6. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, Croce M, Enderson BL, Morris JA, Shatz D, Meredith JW, Ochoa JB, Fakhry SM, Cushman JG, Minei JP, McCarthy M, Luchette FA, Townsend R, Tinkoff G, Block EF, Ross S, Frykberg ER, Bell RM, Davis F 3rd, Weireter L, Shapiro MB. J Trauma. 2000 Aug;49(2):177-87; discussion 187-9.PMID: 10963527 [PubMed - indexed for MEDLINE]

Appendix CT Grading of Splenic Injury Spleen injury scale: (advance one grade for multiple injuries, up to grade III) Grade I: Hematoma: subcapsular, < 10% of surface area Laceration: capsular tear, < 1cm parenchymal depth Grade II: Hematoma: subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter Laceration: 1-3cm parenchymal depth which does not involve a trabecular vessel Grade III: Hematoma: subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5cm or expanding Laceration: >3cm parenchymal depth or involving trabecular vessesls Grade IV: Laceration: laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Grade V: Laceration: completely shattered spleen Vascular: hilar vascular injury which devascularizes spleen

Appendix Size of Hemoperitoneum Small Hemoperitoneum - perisplenic blood or blood in Morrison’s pouch Moderate Hemoperitoneum – blood in one or both pericolic gutters Large hemoperitoneum – blood in one or both gutters with additional blood in pelvis