1. BLUNT SPLEEN
MANAGEMENT
PROTOCOL
2011

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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 Sep;67(3):565-72; discussion PMID: [ 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 May;48(5):801-5; discussion PMID: [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 Oct;140(4):625-31; discussion PMID: 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 Jun;44(6): ; discussion PMID: 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 Apr;56(4):768-72; discussion 773.PMID: 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 Aug;49(2):177-87; discussion PMID: [PubMed - indexed for MEDLINE]

12. 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

13. 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