- Published on
Emergency and Acute Medicine: Splenic Injury
Splenic injury is one of the most important considerations in abdominal trauma, as the spleen is the most commonly injured intra-abdominal organ. Located in the left upper quadrant between the stomach and diaphragm, the spleen is highly vascular and therefore prone to bleeding when injured. In many cases, it is the only organ affected, particularly in blunt trauma scenarios such as motor vehicle accidents, falls, or direct blows to the abdomen. The severity of injury is classified using grading systems based on the extent of hematoma, laceration, and vascular involvement, ranging from minor capsular tears to complete splenic destruction.
The mechanism of injury plays a crucial role in diagnosis. Blunt trauma often results from compression of the spleen between the abdominal wall and posterior structures, while penetrating trauma causes damage through direct tissue disruption and energy transfer. In children, anatomical differences such as a more compliant rib cage and less protective musculature increase susceptibility to splenic injury, while in older adults, reduced physiologic reserve increases the risk of poor outcomes.
Clinical presentation varies widely. Patients may exhibit signs of internal bleeding, including dizziness, weakness, syncope, or hypotension. Local findings often include left upper quadrant tenderness, abdominal distention, and guarding. Classic signs include Kehr sign (referred pain to the left shoulder due to diaphragmatic irritation) and Balance sign (a palpable LUQ mass). Associated findings such as lower left rib fractures or external bruising over the abdomen or flank may further raise suspicion. However, history and physical examination alone are neither sensitive nor specific, making imaging essential.
Initial evaluation follows standard trauma protocols, including airway, breathing, and circulation management. Laboratory studies such as hemoglobin and type and cross-match are obtained but are not diagnostic. Imaging is critical, with focused assessment with sonography for trauma (FAST) used at the bedside to detect free intraperitoneal fluid. While FAST is useful for identifying bleeding, it does not reliably assess the extent of splenic injury. CT scanning with contrast is the gold standard in hemodynamically stable patients, as it provides detailed information about the injury grade and associated intra-abdominal pathology. In unstable patients, immediate surgical intervention may be required without advanced imaging.
Management depends primarily on hemodynamic stability and injury severity. Patients who are unstable or have signs of ongoing hemorrhage typically require emergent laparotomy, often with splenectomy. In contrast, the majority of stable patients—especially those with lower-grade injuries (Grades I–III)—can be managed nonoperatively with close monitoring, serial examinations, and repeat laboratory testing. Angiographic embolization is an important adjunct in selected stable patients with evidence of ongoing bleeding.
Special considerations apply to different populations. In children, nonoperative management is strongly favored to preserve splenic function and reduce the risk of overwhelming post-splenectomy infection. In older adults, however, operative management may be more frequently required due to decreased physiologic reserve and increased risk of complications.
All patients diagnosed with splenic injury require hospital admission for observation or surgical management. Only patients definitively shown to have no splenic or intra-abdominal injury may be safely discharged.
Key pitfalls include relying too heavily on physical examination, missing occult bleeding, and underestimating injury severity in initially stable patients. Early imaging, repeated reassessment, and careful monitoring are essential to prevent delayed recognition of life-threatening hemorrhage.
0 Comments
