Trauma Guideline Manual - SUNY Upstate Medical University

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76____________ Trauma Guideline ManualUpstate Medial University Trauma CenterPRACTICE GUIDELINES: NON-OPERATIVE MANAGEMENT OF SPLENIC INJURIESOBJECTIVES:1. Define situations in which non-operative management of splenic injuries is safe anddesirable.2. Define a clinical pathway for the non-operative management of splenic injuries.DEFINITIONS:Spleen injury:Grade I Subcapsular hematoma, 2 cm expandingLaceration >3 cm in depth or involving trabecular vesselsGrade IV Ruptured intraparenchymal hematoma with active bleedingLaceration involving segmental or hilar vessels producing major devascularization(>25% of spleen)Grade V Shattered spleenHilar vascular injury that devascularizes spleenGUIDELINES:1. Indications: Non-operative management of splenic injury can be considered when all of thefollowing conditions have been met:a. Diagnosis of splenic injury on CT scan.b. Hemodynamically normal patient that has not required or has responded quickly to theresuscitation.c. Grade I-III splenic injury. Consider for Grade IV or V injury in children or adults if nosignificant hemoperitoneum is present.d. No other major intra-abdominal injury.e. Available for monitoring of abdominal exam and blood counts (ie., in a long operativeprocedure) except for short operative procedures.f. No other major sources of blood loss.g. No other premorbid illnesses that suggest the patient could not tolerate blood loss(e.g., severe ischemic heart disease).h. Willingness to take blood transfusion (e.g., not a Jehovah’s Witness).i. Active bleeding (swirl sign) if successful embolizationIn some cases, there will be active bleeding from the spleen as defined by a blush or swirl onthe CT scan or a dropping hematocrit. Consideration should be given to angiography andembolization in these patients. If this option is taken, then consider the time of the embolizationas the “start time” for the following protocol.
Trauma Guideline Manual______________Upstate Medical University Trauma Center772. Protocol:a. Admit all Grade II or higher splenic injuries to telemetry unit. Consider admitting allGrade IV or V splenic injuries to an ICU.i. Monitor hourly vital signs.ii. Bed rest.iii. NPO.iv. Draw serial hematocrit and hemoglobin every 6 hours until stable (within 2%) ontwo consecutive draws.b. When hematocrit is stable and there have been no adverse hemodynamic events:i. Transfer to regular floor or discontinue telemetry.ii. Advance diet.iii. Hematocrit and hemoglobin daily.iv. Bed rest for number of days corresponding to the grade of the splenic injury (e.g.,Grade III = 3 days of bed rest), then may ambulate in the hospital.iv. If stable and tolerating a diet, discharge 1 day after ambulation begins.v. ALL Patients receive a SOLID ORGAN INJURY Cardc. After discharge:i. No school for a week.ii. No physical education for approximately six weeks.iii. No major contact sports (e.g., football) for approximately 3 months.iv. Return to clinic in two weeks.v. Instruct to return to ED if developing worsening left upper quadrant pain, dizziness,syncope or hypotension.d. Failures (requires laparotomy):i. Children: requires >40 ml/kg of blood transfusion to maintain hematocrit >26%.ii. Adults: requires 2 units of blood to maintain hematocrit >26% in the absence ofii.other injuries.Any patient:1) New onset of diffuse peritoneal irritation suggestive of perforated viscus.2) Sudden hypotension unassociated with other bleeding sites.iv. If splenectomy is required, administer vaccines on the next to last hospital day:a) Pneumococcus vaccine (Pneumovax).b) Meningococcus vaccine.c) Hemophilus influenzae vaccine.
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Trauma Guideline Manual - SUNY Upstate Medical University

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