You may have noticed it’s been a little quiet on the ICN site recently. SMACC 2013 is just around the corner and Oli and I have been busy, along with Roger Harris and the other SMACC organisers, getting everything into place so that the conference runs smoothly and lives up to its “best critical care conference ever” claim.

So, in a moment of quiet, here’s a pop quiz on splenic injury to keep your juices flowing.

See you at SMACC!

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Name the top 3 intra-abdominal aneurysms by location.

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1. Aorta.

2. Illiac A.

3. Splenic A

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Which vascular abnormality is more common, true splenic artery aneurysm or splenic artery pseudoaneurysm?

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True aneurysm 0.2 – 10% prevalence.

Pseudoaneurysm < 200 cases reported ever in the English language literature.

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What are the grades of splenic injury?

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Grade 1 – < 1 cm laceration depth, or, <10% subcapsular hematoma
Grade 2 – 1-3 cm laceration depth, or, 10-50% subcapsular hematoma
Grade 3 – >3 cm laceration depth, or, >50% subcapsular hematoma
Grade 4 – hilar injury with >25% devascularization OR contrast blush (active bleeding)
Grade 5 – shattered spleen, or nearly complete devascularization

(See http://regionstraumapro.com/post/43724289994 for tips on remembering this grading)

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Pseudoaneurysms differ from true aneurysms in the lack of an adventitial layer in the dilated portion: True / False?

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True:

A true aneurysm has all three vascular wall layers in the dilated sac.

A pseudoaneurysm has only the media and intimal layers in the wall of the dilation and so is inherently a weaker structure for equal sac volumes, though the medan pseudoaneurysm diameter is larger (4 – 5cm) than that of true splenic artery aneurysms (<3cm).

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List 4 conditions associated with each of true and pseudoaneurysm of the splenic artery.

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True aneurysm: Hypertension, cirrhosis / portal hypertension, liver transplantation, pregnancy and alpha-1 AT deficiency (These are also the high risk groups for which operative or endovascular management may be warranted in assymptomatic individuals)

Pseudoaneurysm: Pancreatitis, trauma, pancreatic surgery, peptic ulcer disease (rare)

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True splenic artery aneurysms typically present as incidental findings on CT.: True / False.

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True.

The rupture incidence is thought to be about 10%. Splenic artery pseudoaneurysms, on the other hand, rarely present assymptomatically and can present with abdominal pain, sudden collapse, haematemesis or PR bleeding and have an untreated mortality of 90%.

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Following blunt abdominal injury, there is no reliable symptom or sign during the latent period that predicts the occurence of delayed splenic rupture.: True / False?

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True, however immediate rupture is more common with major blunt trauma, so that delayed rupture has a greater association with more moderate abdominal trauma.

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A contrast blush on a CT evaluation of a splenic injury may not be due to extravasation.: True / False?

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True. Contrast blush on a CT for splenic injury may be due to extravasation or a splenic artery pseudoaneurysm. The pseudoaneurysm should be treated as it may lead to delayed rupture. True contrast extravasation in the setting of splenic injury should also be treated (EAST guidelines, Level II evidence).

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Post splenectomy encapsulated organism vaccination is best administered 14 days after the operation.: True / False?

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Actually, this is not a fair question as the answer is hotly debated.

A human trial in the Journal of Trauma suggested no difference in antibody titre whether vaccinated on Day 1, 7 or 14, but better functional activity when vaccinated at Day 14. However, this conclusion was based on lab results, not clinical outcome.

A splenectomised rat study demonstrated no difference in clinical outcome with vaccination on Day 1, 7 or 42 with subsequent intraperitoneal inocculation with pneumococcus, but a much greater mortality if not vaccinated at all.

Practice varies in different centres, largely based on the percieved risk of the patient not getting the vaccine at all.

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[su_tabs][su_tab title=”References”]

Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman. Splenic Artery Aneurysms and Pseudoaneurysms: Clinical Distinctions and CT Appearances. AJR 2007; 188:992–999. (Full text article at http://www.ajronline.org/content/188/4/992.full.pdf)

Farhat GA, Abdu RA, Vanek VW. Delayed splenic rupture: real or imaginary? Am Surg. 1992 Jun;58(6):340-5. (PubMed: http://www.ncbi.nlm.nih.gov/pubmed/1596032)

The Trauma Professional’s Blog: Delayed Splenic Rupture: Part 1 – http://regionstraumapro.com/post/20902880020

The Trauma Professional’s Blog: Delayed Splenic Rupture: Part 2 – http://regionstraumapro.com/post/20963514598

The Trauma Professional’s Blog: Splenic Vascular Blush – http://regionstraumapro.com/post/1010325712

The Trauma Professional’s Blog: Grading Spleen Injures – Simplified – http://regionstraumapro.com/post/43724289994

The Trauma Professional’s Blog: EAST Guidelines Update: Spleen Injury – http://regionstraumapro.com/post/4526061906

Shatz, David V., Schinsky, Mark F. et al. Immune Responses of Splenectomized Trauma Patients to the 23-Valent Pneumococcal Polysaccharide Vaccine at 1 versus 7 versus 14 Days after Splenectomy. Journal of Trauma (1998 44(5) 760-766. (PubMed: http://www.ncbi.nlm.nih.gov/pubmed/9603075)

Schreiber MA, Pusateri AE, Veit BC, Smiley RA, Morrison CA, Harris RA. Timing of vaccination does not affect antibody response or survival after pneumococcal challenge in splenectomized rats. J Trauma 45(4):682-697, 1998. (PubMed:

http://www.ncbi.nlm.nih.gov/pubmed/9783606)

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