Jebmh.com Original Research Article Splenic Injury- A Prospective Study from Tertiary Care Ashish Rathore1, Varun Dogra2, Pranav Sharma3 1Senior Resident, Department of General Surgery, Maharishi Markandeshwar University, Solan, Himachal Pradesh. 2Senior Resident, Department of General Surgery, Government Medical College, Jammu. 3Senior Resident, Department of General Surgery, Government Medical College, Jammu. ABSTRACT BACKGROUND Spleen is the most frequently injured organ in blunt trauma abdomen. Injury to Corresponding Author: spleen can result in deadly outcomes. Its management spans from conservative Dr. Varun Dogra, Flat No. 704/C, approach to surgical interventions such as Splenectomy. Royal Palm Apartments, Paloura, Jammu-18000 METHODS E-mail: [email protected] This is a prospective study undertaken at Government Medical College, Jammu, DOI: 10.18410/jebmh/2019/646 from 1st November 2017 to 31st October 2018. All patients with blunt splenic trauma, resulting from falls or Road Traffic Accidents, admitted to the Emergency Financial or Other Competing Interests: None. Department of General Surgery, were thoroughly examined with concomitant resuscitation. After evaluation, they were either operated or managed How to Cite This Article: conservatively. Rathore A, Dogra V, Sharma P. Splenic injury- a prospective study from tertiary RESULTS care. J. Evid. Based Med. Healthc. 2019; Out of fifty patients enrolled in this study, majority was males in the 20-40 years 6(49), 3087-3091. DOI: 10.18410/jebmh/2019/646 age group. They presented mostly with pain and tenderness in upper abdomen. Other associated injuries were also present in 16 cases. More than half of the Submission 14-11-2019, patients (59.26%) suffered from grade 2 splenic injuries while on 14.81% suffered Peer Review 19-11-2019, from grade 5 splenic injury. 14 patients were managed conservatively, 36 patients Acceptance 27-11-2019, Published 09-12-2019. required operative intervention. Complications were recorded in 20 while there were 3 mortalities. CONCLUSIONS This study emphasises the use of CT and Ultrasonography in the evaluation and adoption of a conservative approach in managing stable cases of isolated low- grade splenic trauma. KEYWORDS Spleen, Trauma, Road Traffic Accidents J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3087 Jebmh.com Original Research Article BACKGROUND operative management of blunt splenic trauma. In some series there is increase in the frequency of non-operative 3 Following blunt abdominal trauma, spleen is the most management for equivalent injuries from 11 to 71%. frequently injured solid organ and it represents around 31- The strategy for management of blunt splenic injury, 35% and sometimes up to 50% of all abdominal solid organ which may have an impact on mortality, has changed. Blunt injuries.1 Majority of cases with splenic injury is observed in splenic injury has various therapeutic options depending on second and third decade of life. This being the most active the patient’s hemodynamic condition and the accompanying period of life when movements in motor vehicles and injuries of other organs. Surgery remains the gold standard outdoor works result in increased risk of trauma.2 Spleen is for treating patients with splenic injuries with hemodynamic susceptible to injury during trauma to the left lower thorax instability and it has constituted 31-35% or even up to 50% or left upper abdomen. Other injuries that may be of cases. A distinct trend in spleen saving has been observed associated with it include injuries to the rib cage, and increasing numbers of patients with these injuries have diaphragm, pancreas, and bowel.3 been treated non-operatively, including patients with The delayed diagnosis of blunt splenic injury (BSI) abdominal multi-organ injuries. Non-operative treatment might result in poor outcome with a reported high mortality combined with splenic artery angioembolization is among rate, ranging from 7 to 18%. The initial hours of blunt the options for the treatment of hemodynamically stable 7 trauma abdomen are extremely crucial for the patient. patients, regardless of splenic injury severity. When the spleen is injured, blood may be released into the The conservative management of splenic injuries has peritoneal cavity and the amount of bleeding depends on evolved over the past few decades with the realisation of the grade of the splenic injury. Low grade (I & II) injuries the importance of the spleen in immunological defence are usually admitted to the surgical ward and are treated against encapsulated organisms and a better understanding conservatively. While, high grades of blunt splenic injuries of the role of non-operative management of splenic 3 (≥grade III) are admitted to the intensive care unit and their injuries. Non-operative management in adults have management depends on the clinical condition and progress achieved success rates ranging from 68 to 83% and is of the patient condition.1 considered to be the cornerstone of treatment in 8 A hematoma of the spleen does not bleed into the hemodynamically stable patients. Non-operative abdomen at first but may rupture and bleed in the first few management represents the progression of ‘save our spleen’ days after injury. An injured or ruptured spleen can make concept which was initially used for children and later on the abdomen painful and tender. The pain is in the left side extended to adults. The only absolute indication for 9 of the abdomen just below the rib cage. Sometimes the pain emergency laparotomy is hemodynamic instability. is felt in the left shoulder. If enough blood leaks out, blood Hemodynamic instability is the primary reason for pressure falls and people feel light-headed, have blurred surgical management. Salvage procedures including vision and confusion, and lose consciousness.4 splenorrhaphy or partial resection of the spleen are The initial assessment of patients with suspected blunt appropriate in certain situations such as when carried out as abdominal trauma should focus on the abdominal an adjunct to the repair of other abdominal organ injuries. examination (tenderness and abdominal wall ecchymosis), Splenectomy should be avoided as far as possible, because vital signs, and response to resuscitation. In patients with it leads to increased risks of severe infections and clot evidence of shock or overt serious injury, blood should be formation. However, the risks should be balanced against 10 immediately drawn for all laboratory investigations and the risk of re-bleeding after salvage. adequate intravenous (IV) access should be obtained for We wanted to estimate the prevalence, severity and resuscitation. There is considerable variability in the mode of splenic trauma, evaluate the other associated intra- abdominal injuries, evaluate various available investigations definition of hemodynamic instability.5 Clinical examination for detection of splenic injuries and evaluate various alone is inadequate because patients may have altered modalities of treatment and common complications. mental status and other distracting injuries. Initial resuscitation along with focused assessment with solography in trauma (FAST) and computed tomography METHODS (CT) abdomen are very beneficial to detect those splenic injury in patients with minimal and clinically undetectable signs of abdominal injury.6 It was a prospective study which was undertaken at FAST is particularly useful in hemodynamic ally unstable Government Medical College, Jammu in Department of patients to look for free abdominal fluid (sensitivity 98%), Surgery from 1st November 2017 to 31st October 2018. All as it is highly accessible, quick to perform, portable, and patients with blunt splenic trauma, resulting from falls or non-invasive. The technique does however have limitations Road Traffic Accidents, admitted to the Emergency in obese patients as it is operator dependent and intra- Department of General Surgery, being thoroughly examined abdominal injuries may be missed. Computed tomography with concomitant resuscitation. scanning has become the gold standard for imaging in blunt The choice of diagnostic approach depends on the abdominal trauma and in the identification of splenic hemodynamic status of the patients. The most utilized injuries. This has contributed to the development of non- primary modalities are FAST and CT scan. The decision for J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3088 Jebmh.com Original Research Article operative or non-operative management depends on the splenic injury along with associated injury to other intra outcome of the clinical examination and results of diagnostic peritoneal and retro peritoneal structures. In our study, the tests. All hemodynamically unstable patients were relative percentage of various Grades of splenic injury immediately taken to the operating room following an FAST (Table 3) was 0% (Grade-I), 11.11% (Grade-II), 59.26% Scan to undergo an emergency laparotomy, while those (Grade-III), 14.81% (Grade-IV) and 14.81% (Grade-V). who were stable were evaluated by CT) scan of the CECT abdomen besides diagnosing splenic trauma also abdomen and pelvis and x-ray chest and abdomen. diagnosed hepatic injuries in 5 cases (10%) and renal In those patients who were hemodynamically stable, injuries in 4 cases (8%). Hepatic injuries include Grade II splenic injuries were Graded I to V according to the and Grade IV while renal