In most trauma textbooks, the most commonly injured solid organ is the spleen. There is a lot of work available that tells trauma professionals how to detect and manage spleen injuries. However, the treatment of the sequelae is less clear cut. We know that the platelet count generally rises after spleen injury, and especially if it is removed. We think we know that we should be on alert if the platelet count goes over 1 M per microliter (ul) to avoid thrombisis.
What happens during the usual hospital course? Is venous thrombosis actually a problem? A group at St. Michael’s Hospital in Toronto performed a 5 year retrospective review of their patients with splenic injury to try to answer these questions. Children and patients with known pre-existing coagulopathy or that were taking anticoagulants were excluded. All were managed with prophylactic low molecular heparin, although the specific product or protocol were not described.
Here are the factoids:
- A total of 156 patients were enrolled over 5 years. – This is a relatively low number (31/year). In contrast, here in bustling metropolitan St. Paul we see 80-100 per year.
- Nonoperative management was performed in 84% of cases, with angio-embolization added in another 8%. The other 8% were taken to OR, where most underwent splenectomy. – This is spot on with national data. However, looking at their injury grade breakdown, it seems like they take out a higher than usual number of low grade spleens.
- Platelet count rose steadily after admission, peaking at day 16-17.
- Splenectomy patients had a mean peak platelet count of 890K/ul.
- Nonop management patients had a mean peak of 604K/ul.
- Extreme thrombocytosis (counts > 1M/ul) occurred in 25 patients (16%). It occurred in 41% of splenectomy patients, but only 6% of nonop patients.
- Although DVT and PE occurred in these patients (8%, which seems a bit high), there was no association with thrombocytosis, extreme thrombocytosis, or aspirin use. – This is most likely due to the small size of the study.
Bottom line: This small study provides some interesting and important information regarding the platelet count trend after splenic injury. Although there was not enough power to look at the association with DVT, PE, and the value of aspirin treatment for extreme thrombocytosis, the platelet count trend info was very interesting. It looks like we should be checking a platelet count about 2-3 weeks after injury to make sure it’s not reaching extreme levels. This can be scheduled during their postop or post-discharge visit. A reminder should also be sent to the primary care physician to be on the lookout for extreme thrombocytosis for the first three weeks post-injury.
Reference: Thrombocytosis in splenic trauma: In-hospital course and association with venous thromboembolism. Injury, in press, 2016.