New Clinical Practice Guidelines, September 2017

John Anello; Brian Feinberg; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO; Yonah Korngold; John Heinegg. Sam Shlomo Spaeth

Disclosures

September 15, 2017

In This Article

Splenic Trauma

Guidelines on splenic trauma by the World Society of Emergency Surgery[17]

  • The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient.

  • E-FAST is effective and rapid to detect free fluid.

  • CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients.

  • Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up.

  • Injury grade on CT scan, extent of free fluid, and the presence of pseudoaneurysm (PSA) do not predict nonoperative management (NOM) failure or the need of operative management (OM).

  • Patients with hemodynamic stability and absence of other abdominal organ injuries requiring surgery should undergo an initial attempt of NOM irrespective of injury grade.

  • NOM of moderate or severe spleen injuries should be considered only in an environment that provides capability for patient intensive monitoring, angiography/angioembolization (AG/AE), an immediately available OR, and immediate access to blood and blood products; or alternatively in the presence of a rapid centralization system and only in patients with hemodynamic stability and absence of other internal injuries requiring surgery.

  • NOM in splenic injuries is contraindicated in the setting of unresponsive hemodynamic instability or other indications for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement).

  • In patients being considered for NOM, CT scan with intravenous contrast should be performed to define the anatomic spleen injury and identify associated injuries.

  • AG/AE may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective of injury grade.

  • Strong evidence exists that age above 55 yr, high injury severity score (ISS) and moderate-to-severe splenic injuries are prognostic factors for NOM failure. These patients require more intensive monitoring and higher index of suspicion.

  • In WSES classes II–III spleen injuries with associated severe traumatic brain injury, NOM could be considered only if rescue therapy (OR and/or AG/AE) is rapidly available; otherwise, splenectomy should be performed.

Pediatric Patients

  • NOM is recommended as first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma.

  • Patients with moderate-severe blunt and all penetrating splenic injuries should be considered for transfer to dedicated pediatric trauma centers after hemodynamic stabilization.

  • NOM of spleen injuries in children should be considered only in an environment that provides capability for patient continuous monitoring, angiography, trained surgeons, an immediately available OR, and immediate access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred.

  • NOM should be attempted even in the setting of concomitant head trauma, unless the patient is unstable and this might be due to intra-abdominal bleeding.

For further reading, see Spleen Trauma Imaging

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....