Splenic Rupture Medical Slides

Present the evidence-based NOM approach: Inclusion criteria — hemodynamically stable (or responding to initial resuscitation), no peritonitis, no other indication for laparotomy, ability to monitor (ICU for grades III-V). Protocol: NPO, bed rest, serial abdominal exams every 4-6 hours, serial hemoglobin (every 6 hours × 24 hours, then every 12 hours), CT with contrast blush → angioembolization. NOM success rates by grade: I-II (95-98%), III (90-95%), IV (80-85%), V (60-70%, often require delayed splenectomy). Failure criteria triggering OR: hemodynamic instability despite resuscitation, peritonitis, transfusion >4 units in 24 hours, declining hemoglobin despite transfusion. Eastern Association for the Surgery of Trauma (EAST) guidelines support NOM regardless of grade if hemodynamically stable.

Present the expanding role: angioembolization indicated for CT contrast blush (active extravasation), pseudoaneurysm, AV fistula, or high-grade injury (IV-V) being managed nonoperatively. Two techniques: proximal (main splenic artery) — reduces perfusion pressure, preserves some splenic function via collaterals, lower rebleed rate. Distal (selective super-selective) — targets specific bleeding branch, better splenic preservation, but may miss other injured branches. AAST prospective observational study: angioembolization increased NOM success for grades IV-V from 67% to 87%. Complications: splenic infarction (20-30%, usually partial and asymptomatic), abscess (4%), coil migration, contrast nephropathy. Post-embolization management: continue ICU monitoring, repeat CT if clinical concern.

Present the critical importance: overwhelming post-splenectomy infection (OPSI) is a lifelong risk (0.5-1% per year) with >50% mortality once established. Encapsulated organisms: Streptococcus pneumoniae (most common), Haemophilus influenzae, Neisseria meningitidis. Vaccination protocol (ideally 14 days post-splenectomy, or pre-operatively if planned): PCV13 first → PPSV23 at least 8 weeks later (then PPSV23 boost at 5 years), MenACWY + MenB, Hib vaccine. Annual influenza vaccine. Consider daily penicillin prophylaxis (amoxicillin 250-500 mg) for first 1-2 years and for children until age 16. Patient education: medical alert identification, seek immediate medical care for any fever >38.5°C (empiric antibiotics: amoxicillin-clavulanate or fluoroquinolone if penicillin allergic).