Rosen & Barkin's 5-Minute Emergency Medicine Consult (669 page)

• Patients with significant spinal cord or column injury should be treated at a regional trauma center.
  
• Unstable spinal column injury
  
• Spinal cord or root injury
  
• Ileus
  
• Pain control
  
• Concomitant traumatic injury
  
• ICU-level care based on severity of injuries
  

Stable minor fractures after orthopedic or neurosurgical evaluation.

Outpatient neurosurgical or orthopedic follow-up as indicated after appropriate ED or inpatient evaluation and treatment.

• Suspect and evaluate for thoracic spine injury in any trauma patient.
  
• CT evaluation is indicated for any patient with significant mechanism, pain, or tenderness; distracting injury or injury at another spinal level; intoxication or altered mental status.
  
• Maintain spinal immobilization until cleared by radiologic and clinical exam.
  
• Early consultation with spine surgeon if presence of fracture, neurologic deficit, or instability.
  
• Treatment with high-dose steroids is currently an area of controversy. Begin treatment within 8 hr of injury if initiating high-dose steroid protocol.
  

• Bagley LJ. Imaging of spinal trauma.
  Radiol Clin North Am
  . 2006;44(1):1–12, vii.
  
• Bracken MB. Steroids for acute spinal cord injury.
  Cochrane Database Syst Rev
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  2012;1:CD001046.
  
• Chiles BW 3rd, Cooper PR. Acute spinal injury.
  N Engl J Med
  . 1996;334(8):514–520.
  
• Hockberger RS, Kaji AH, Newton E. Spinal injuries. In: Marx JA, Hockberger RS, Walls RM, eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. Philadelphia, PA: Mosby; 2010:337–375.
  
• Inaba K, Munera F, McKenney M, et al. Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: A review of the literature.
  J Trauma
  . 2006;60:915–920.
  

CODES

• 805.2 Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury
  
• 839.21 Closed dislocation, thoracic vertebra
  
• 847.1 Sprain of thoracic
  

BASICS

• The spleen is formed by reticular and lymphatic tissue and is the largest lymph organ.
  
• The spleen lies posterolaterally in the left upper quadrant (LUQ) between the fundus of the stomach and the diaphragm.
  

• The spleen is the most commonly injured intra-abdominal organ:
  
  • In nearly 2/3 of cases, it is the only damaged intraperitoneal structure
    
  • Blunt mechanisms are more common
    
• Motor vehicle accidents (auto–auto, pedestrian–auto) are the major cause (50–75%), followed by blows to the abdomen (15%) and falls (6–9%)
  
• Mechanism of injury and kinematics are important factors in evaluating patients for possible splenic injury.
  
• Splenic injuries are graded by type and severity of injury [American Association for the Surgery of Trauma (AAST) criteria]:
  
  • Grade I:
    
    • Hematoma: Subcapsular, <10% surface area
      
    • Laceration: Capsular tear, <1 cm in parenchymal depth
      
  • Grade II:
    
    • Hematoma: Subcapsular, 10–50% surface area; intraparenchymal, <5 cm in diameter
      
    • Laceration: Capsular tear, 1–3 cm in parenchymal depth and not involving a trabecular vessel
      
  • Grade III:
    
    • Hematoma: Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥5 cm or expanding
      
    • Laceration: >3 cm in parenchymal depth or involving the trabecular vessels
      
  • Grade IV:
    
    • Laceration: Involving the segmental or hilar vessels and producing major devascularization (>25% of spleen)
      
  • Grade V:
    
    • Laceration: Completely shattered spleen
      
    • Vascular: Hilar vascular injury that devascularizes the spleen
      

• Poorly developed musculature and relatively smaller anteroposterior diameter increase the vulnerability of abdominal contents to compressive forces.
  
• Rib cage is extremely compliant and less prone to fracture in children but provides only partial protection against splenic injury.
  
• Splenic capsule in children is relatively thicker than that of an adult; parenchyma of spleen seems to contain more smooth muscle than in adults.
  
• Significant abdominal injury occurs in only about 5% of child abuse cases but is the 2nd most common cause of death after head injury.
  

DIAGNOSIS

• In blunt trauma, note the type and direction (horizontal or vertical) of any deceleration or compressive forces:
  
  • Injuries are caused by compression of the spleen between the anterior abdominal wall and the posterior thoracic cage or vertebra (e.g., lap-belt restraints).
    
• In penetrating trauma, note the characteristic of the weapon (type and caliber), distance from the weapon, or the type and length of knife or impaling object:
  
  • Injuries result from a combination of the kinetic energy and shear forces of penetration.
    

• Systemic signs from acute blood loss:
  
  • Syncope, dizziness, weakness, confusion
    
  • Hypotension or shock
    
• Local signs:
  
  • LUQ abdominal tenderness
    
  • Palpable tender mass in LUQ (Balance sign)
    
  • Referred pain to the left shoulder (Kehr sign)
    
  • Abdominal distention, rigidity, rebound tenderness, involuntary guarding
    
• Contusions, abrasions, or penetrating wounds to the chest, flank, or abdomen may indicate underlying spleen injury.
  
• Fractures of lower left ribs are commonly seen in association with splenic injuries.
  

Age-related difficulties in communication, fear-induced uncooperative behavior, or a concomitant head injury make clinical exam less reliable.

• History and physical exam are neither specific nor sensitive for splenic injury.
  
• Adjunctive imaging studies are required.
  

• No hematologic lab studies are specific for diagnosis of injury to the spleen.
  
• Obtain baseline hemoglobin, type and cross-match, and chemistries.
  

• Plain abdominal radiographs:
  
  • Too nonspecific to be of value
    
  • CXR findings suggestive for splenic injury:
    
    • Left lower rib fracture(s)
      
    • Elevation of left hemidiaphragm
      
    • Medial displacement of gastric bubble (Balance sign)
      
    • Left pleural effusion
      
• Ultrasound:
  
  • Routinely performed at bedside in trauma patients as part of focused assessment with sonography (FAST)
    
  • Primary role is detecting free intraperitoneal blood, which may suggest splenic injury
    
  • Does not image solid parenchymal damage well
    
  • Technically compromised by uncooperative patient, obesity, substantial bowel gas, and subcutaneous air
    
• CT scan:
  
  • Noncontrast CT is procedure of choice in stable patient due to speed and accessibility
    
  • Depicts the presence and extent of splenic injury and adjacent organs, including the retroperitoneum
    
  • Provides the most specific information in patients stable enough to go to the CT scanner
    
• MRI:
  
  • May be applicable to subset of hemodynamically stable patients who cannot undergo CT scan (e.g., allergic to IV contrast)
    
• Angiography:
  
  • Has been added to the diagnostic and treatment options for selected cases
    

• Diagnostic peritoneal lavage (DPL):
  
  • Extremely sensitive for the presence of hemoperitoneum although nonspecific for source of bleeding and does not evaluate retroperitoneum
    
  • Largely replaced by the FAST exam in most major trauma centers.
    

• Intraperitoneal organ injury, especially liver
  
• Injury to retroperitoneal structures
  
• Thoracic injury
  

TREATMENT

• Obtain details of injury from pre-hospital providers.
  
• IV access
  
• Penetrating wounds or evisceration should be covered with sterile dressings.
  

• Airway management (including C-spine immobilization)
  
• Standard Advanced Trauma Life Support (ATLS) resuscitation measures:
  
  • Adequate IV access, including central lines and cutdowns, as dictated by the patient’’s hemodynamic status
    
  • Fluid resuscitation, initially with 2 L of crystalloid (NS or lactated Ringer solution), followed by blood products as needed