Category Archives: General

General

Vaccines After Splenic Trauma

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The current standard of care is to vaccinate patients after splenectomy to prevent overwhelming post-splenectomy sepsis (OPSS). The real questions are, is this reasonable and is it needed after splenorrhaphy or angioembolization, too?

The spleen was recognized as contributing to infection resistance in the early 1900s. A study on post-splenectomy sepsis that has been widely quoted was published in 1952. Unfortunately, the children involved all had hematologic disorders, so it is difficult to determine if their sepsis deaths were due to splenectomy or their underlying disease.

Reports of sepsis and death continued to accumulate in the latter half of the last century, but there was a tremendous amount of overlap in patient cases. Richardson reviewed the world literature to date and found that, as of about 2003, there were roughly 70 total cases worldwide since the beginning of time, with a death rate of about 30%. Basically, there are more published papers and reports on death from OPSS than there are actual cases!

This flawed data directed a push toward splenorrhaphy and then to nonoperative management of splenic injury. Guidelines have been developed and revised that suggest that the following vaccines should be given to patients with splenectomy:

  • Pneumovax 23 – .5cc SQ, booster every 6 years
  • Haemophilus B conjugate – .5cc IM, no booster
  • Meningococcal vaccine (polysaccharide or diphtheria conjugate) – .5cc (route depends on vaccine), booster status unclear

There is no good data at all on vaccine administration after angioembolization. Animal studies suggest that at least 50% of the spleen must be perfused by the splenic artery in order to maintain immune competence. Patients who have CT or angiographic evidence that a significant portion of the spleen is not perfused should probably undergo vaccination.

Given the rarity of OPSS and the even lower probability of dying from it, a definitive study regarding the usefulness of spleen vaccine administration will never be done. So we are stuck with giving them in spleen-injured or spleen-free patients even though the usefulness can never be proven.

Reference: J David Richardson. Managing Liver and Spleen Injuries. J Am Col Surg 200(5):648-669, 2005.

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General

Grading Spleen Injuries Simplified

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Spleen injury grading is not as complicated as people think! The grading system ranges from Grade I (very minor) to Grade V (shattered, devascularized). 

There is one nuance that people frequently don’t appreciate: multiple injuries can increase the grade. Technically, multiple injuries advance the maximum grade by one point, up to a maximum of Grade 3. So Grade 1 + Grade 1 = Grade 2, but Grades 2+2 = 3! Weird arithmetic!

The vast majority of injuries are Grades 1 to 3, and they are actually the easiest to grade. I use this simple rule: 1 and 3, 10 and 50.

The first set of numbers indicates the depth of a laceration in centimeters.

  • Grade 1 – < 1 cm laceration depth
  • Grade 2 – 1-3 cm laceration depth
  • Grade 3 – >3 cm laceration depth

The second set of numbers refers to size of a subcapsular hematoma in percent of the total surface area of the spleen. Hint: most of these low grades are determined by laceration depth. Very few actually have sizable subcapsular hematomas. So memorize the 1-3 rule first!

  • Grade 1 – <10% subcapsular hematoma
  • Grade 2 – 10-50% subcapsular hematoma
  • Grade 3 – >50% subcapsular hematoma

Grades 4 and 5 use other criteria, but in general if it looks completely pulped it’s a 5, and if it’s a little less pulped, it’s a 4.

  • Grade 4 – hilar injury with >25% devascularization OR contrast blush (active bleeding)
  • Grade 5 – shattered spleen, or nearly complete devascularization

That’s it! Tomorrow I’ll talk about the real significance of the contrast blush.

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Spleen Week

This week I’ll be covering spleen injuries. The answer to the question “What is wrong with this spleen” is: 1. There is a spleen laceration (grade cannot be determined from this one slice) and 2. There is a contrast blush.

Today I’ll cover grading and tomorrow I’ll talk about the significance of blushes.

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How Often Are Imaging Studies Repeated After Trauma Transfers?

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Smaller trauma hospitals, both designated and undesignated, are the front line for the initial care of the majority of trauma patients. Many patients can be evaluated and sent home or admitted to the initial hospital. More severely injured patients are commonly transferred to the nearest Level I or Level II trauma center for care of injuries requiring specialists.

Imaging studies such as conventional xray and CT scan are a necessary part of the initial trauma evaluation. But is it necessary to do a full radiographic evaluation, even when it is known that the patient will have to be transferred?

Researchers at Dartmouth Hitchcock Medical Center examined the issue of repeat imaging at their Level I center. They looked at 138 patients that were transferred to them from other rural hospitals. They found that 75% underwent CT scanning prior to transfer, and 58% underwent repeat scanning upon arriving at Dartmouth.

The authors discovered the following:

  • Head CTs were repeated 52% of the time, primarily due to clinical indications
  • Spine reconstructions were repeated 33-50% of the time due to inadequate reconstruction technique
  • Chest (31%) and abdomen (20%) were repeated due to inappropriate use of IV contrast
  • 13% of image disks used incompatible software
  • 7% of images were not sent with the patient

Here are my recommendations for imaging by hospitals that refer patients to Level I or II trauma center:

  • Obtain the essential plain films recommended by ATLS (chest, pelvis)
  • If an obvious injury requiring transfer is found on exam (e.g. open fracture) do no further studies
  • Obtain any imaging studies needed to decide if you can admit the patient to your own hospital (example: abdominal CT for abdominal pain and negative FAST. Keep if no injury, transfer if solid organ injury)
  • As soon as an injury is identified that mandates transfer, do no further studies
  • Always send image disks with the patient
  • Work with your referral trauma center to obtain a copy of their CT imaging protocols so if you do need to perform a study you can duplicate their technique

Reference: Gupta et al. Inefficiencies in a Rural Trauma System: The Burden of Repeat Imaging in Interfacility Transfers. J Trauma 69(2):253-255, 2010.

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