Date:
Patient:
Reason for Visit:
Initial evaluation for blunt or penetrating trauma with suspected splenic injury
Follow-up for diagnosed splenic trauma
Assessment of bleeding, hemodynamic stability, and management plan
Evaluation of treatment response or potential complications
History:
Presenting Illness:
Mechanism of injury (blunt trauma – e.g., motor vehicle crash, fall – or penetrating trauma – e.g., gunshot wound, stabbing)
Onset and severity of abdominal pain (left upper quadrant)
Nausea, vomiting, or other gastrointestinal symptoms
Signs of internal bleeding (hypotension, lightheadedness, weakness)
Past medical history (relevant conditions, medications)
Physical Exam:
General: Assess vital signs (blood pressure, heart rate, respiratory rate) and overall health.
Abdominal: Evaluate for tenderness, guarding, or distention in the left upper quadrant. Look for signs of internal bleeding (palpable mass, Cullen’s sign – periumbilical bruising, Grey Turner’s sign – flank ecchymosis).
Rectal Exam: May reveal blood (suggestive of internal bleeding).
Diagnostic Tests (may be ordered depending on clinical suspicion):
Laboratory Tests:
Complete blood count (CBC) – to assess for anemia (low red blood cell count) due to bleeding.
Blood type and Rh factor – for blood transfusion preparation if necessary.
Imaging Studies:
Abdominal ultrasound – initial imaging modality to assess for free fluid in the abdomen (suggestive of bleeding) and potential splenic lacerations.
CT scan with contrast – definitive imaging study for diagnosing splenic injury, showing size, location, and extent of bleeding.
Assessment:
Clinical suspicion of splenic injury: Based on history of trauma and physical exam findings.
Confirmation of splenic injury: Requires imaging studies like CT scan.
Grading of splenic injury (based on severity): Guides treatment decisions.
Grade I-II (minor lacerations): Usually managed conservatively.
Grade III-V (major lacerations or shattered spleen): Higher risk of bleeding, may require intervention.
Hemodynamic stability: Assesses the severity of bleeding and need for immediate intervention.
Plan:
Treatment approach depends on several factors:
Grade of splenic injury
Hemodynamic stability
Patient’s overall health
Non-operative management (considered for stable patients with low-grade injuries):
Close observation in an intensive care unit (ICU) setting with frequent vital sign monitoring and serial abdominal exams.
Blood transfusions may be needed if bleeding occurs.
Successful non-operative management avoids the risks of surgery.
Splenic artery embolization: Minimally invasive procedure to block bleeding arteries in the spleen using coils. May be an option for select patients.
Splenectomy (surgical removal of the spleen): Indicated for high-grade injuries, hemodynamic instability, or persistent bleeding. Minimally invasive laparoscopic approach preferred when possible.
Pain management: Important throughout the management course to improve patient comfort.
Follow-up:
For patients managed conservatively, close follow-up with serial imaging studies to monitor for delayed bleeding or complications.
Depending on the severity of injury, follow-up may extend for several weeks or months.
Prophylactic antibiotics after splenectomy (to prevent post-splenectomy sepsis) may be recommended.
Patient education: Provide information about splenic trauma, its causes, treatment options, and potential complications.
Discuss the importance of activity restrictions and follow-up appointments.
Educate patients about the increased risk of infection after splenectomy and the importance of vaccinations.
Encourage open communication about any concerns or questions.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of splenic trauma.