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Management of Splenic injury following blunt abdominal trauma Dr.D.Sirish Bharadwaj General Surgery
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Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Mar 02, 2019

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Page 1: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Management of Splenic injury following blunt 

abdominal traumaDr.D.Sirish Bharadwaj

General Surgery

Page 2: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Discussion under the following headingsIntroduction to traumaBlunt injury abdomen ‐ IntroductionMost commonly involved organsPatho‐physiology of injuryInitial management General physical examinationClassification based on hamodynamic statusMajor organ injuries

Page 3: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Splenic injuries:IntroductionTypesGeneral managementClinical presentationDiagnosisTreatment 

Page 4: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

          INTRODUCTIONWHAT IS TRAUMA?Trauma is the study of medical problems associated with physical injury, which is an adverse effect of physical force upon a person.

Varieties:Mechanical:                         1)Blunt                        2)PenetratingThermalChemicalIonizing radiation etc..

Page 5: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

“Golden Hour”ACS concept that deaths & complications are 

reduced when trauma victims receive definitive treatment within the 1st hour after injury

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BLUNT INJURY ABDOMENBlunt abdominal injuries carry a greater risk of morbidity and mortality than peneterating abdominal injuries.  

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Most commonly involved organs:

Spleen (40‐55%)  Liver (35‐45%)Small bowel (5‐10%)

Page 8: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Pathophysiology of injury

Page 9: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Crushing effect: Compression from crush between solid objects such as the steering wheel/seat belt & the vertebrae

 

Seat belt injuries ‐ “seat belt sign” = highly correlated with intraperitoneal injury

Acceleration and deceleration forces  → shear injury

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Initial management of blunt injury abdomen

Page 11: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Primary survey and resuscitation:

A – AirwayB – BreathingC – CirculationD – DisabilityE – Exposure

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Secondary SurveyA – AllergyM – MedicationP –  Past medical historyL –  Last mealE –  Events of the incident

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Events of the incident

Details about accidentDamage to carVelocitySteering wheel damageType of seatbelts usedAir bags deployed All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury

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Secondary survey (cont)Subsequent physical examRe‐evaluationAnalgesiaDocumentation & legal considerationsDefinitive care & transfer

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Physical ExaminationExternal injuries:Bruise or ecchymosis around umbilicus/flanks/hypochondriac regions

Grey Turners sign & Cullens sign – indicative of retroperitoneal haemorrhage

London sign – patterned abrasion of the abdominal wall – impression of the object causing the impact :

• Tyre marks,• Pattern of clothing/• Seat beltSignificance:  if positive, then the initial impact is severe & the chances of having internal organ injury is more.

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LONDON SIGN

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CULLENS SIGN

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GREY‐TURNERS SIGN

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Abdominal findings:Distension of abdomenTenderness – suggests inflammation/haemoperitoneumRebound tendernessGuarding, rigidityFluid thrillObliteration of liver dullness – suggests perforation of hollow viscera

Increased hepatic/splenic dullnessFree fluid in abdomen detected by shifting dullnessAbsent or decreased bowel sounds

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Unstable vitalsHypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury.

Unexplained Hypotension associated with significant  blunt abdominal trauma, one should exclude intraperitoneal hemorrhage with solid organ injury or vascular injury.

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Abdominal injuries categorised into:Haemodynamically normal:  Full investigations & planned treatment

Haemodynamically stable: Limited investigationsNon‐operative : Angio embolizationOperative : Which cavity?

Haemodynamically unstable: Immediate surgical correctionTrauma laparotomy

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MAJOR ORGAN INJURIES

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Hepatic Injuries2nd most commonly injured intraabdominal organAssociated with R 8‐12 rib fracturesSubcapsular hematomasLacerationsVascular injuries

TreatmentDamage Control ‐ Pack the liver to control bleeding & close at a later timeOperative repair

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Hollow Organ InjuriesSmall or large bowel, gastric injuriesPerforation with spillage of contents into peritoneal cavitySigns & symptoms of peritonitis

TreatmentSurgical repairDiversion of the injured bowel with re‐anastamosis at a later time

TPN 

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        SPLENIC INJURIES

Page 26: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Introduction to splenic injuriesAssociated with left rib 10‐12 fxs, falls, contact sports, assaults

Most commonly injured organ from blunt trauma 40% have no symptomsBleeding may be contained by capsule

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Types of splenic injurySubcapsular haematomaLaceration of spleenPolar tearAvulsion of splenic pedicle

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General Management of Abdominal TraumaScene survey for MOIRapid evaluation of the patientSecure airway with spinal precautionsProvide ventilatory supportHigh concentration O2Stabilize – Direct pressure, compression mattress external sheet or pelvic binder for hemorrhage

Wound managementVitals monitoringManage shockCardiac monitorRapid and safe Transport

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Clinical presentationClassical features of splenic injuries: seen in severe injuries and polar tear  with symptoms and signs of intraperitoneal haemorrhage.

Silent: There may be slight pain abdomen with no symptoms & signs. 

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Delayed rupture : seen in subcapsular haematomaMild left hypochondriac pain with no symptoms or signs at initial presentation and the injury is often missedAfter 7‐14 days the haematoma grows and ruptures and patient presents with symptoms & signs of intraperitoneal haemorrhage.

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Classical features of major splenic traumaGeneral symptoms and signs of internal haemorrhage: Pallor Tachycardia Hypotension Restlessness Sweating Deep, sighing respiration Cold, clammy extremities Collapsed veins

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There may be cutaneous bruising in the left upper quadrant of abdomen.

Increasing left upper abdominal pain & tendernessIncreasing left upper abdominal guarding & rigidityIncreasing abdominal distension

Symptoms & Signs of splenic injury

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(cont)Diminished or absent bowel sounds.Kehr’s sign ‐ Referred pain in the left shoulder on elevation of foot end due to irritation of the adjacent diaphragm

Ballance’s sign – fixed dullness in the left flank due to clotted blood around the spleen and shifting dullness in the right flank due to unclotted blood in the peritoneal cavity. 

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            DIAGNOSIS  1. Laboratory tests2. Radiological investigations 

Page 35: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Lab tests:

Complete haemogram – May have ↓ Hct, ↑ WBCinitially Hb% may be normal for 6 hrs, 

May have, ↑ lactate, LFTs, lipase, toxicology screen.

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Radiological investigationsTo determine if there is hemoperitoneum or organ injury requiring surgical repair

      X‐ray abdomen erectFAST  DPL  CT

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Plain abdominal filmIncrease in splenic shadow 

with hazinessObliteration of left psoas 

shadowIndentation of fundic gas 

shadowLeft colonic gas shadow 

displaced downwardFree fluid between gas‐

filled intestinal coilsLeft diaphragmatic 

elevationLeft lower lobe atelectasisLeft pleural effusion if ass 

with fracture ribs Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of thesplenic flexure (arrow)

Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of thesplenic flexure (arrow)

Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of thesplenic flexure (arrow)

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FASTFocused assessment with sonography for trauma (FAST) To diagnose free intraperitoneal blood after blunt trauma4 areas: Perihepatic & hepato‐renal space (Morrison’s pouch) Perisplenic Pelvis (Pouch of Douglas/rectovesical pouch) Pericardium (subxiphoid)

sensitivity 60 to 95% for detecting 100 mL ‐ 500 mL of fluid

Extended FAST (E‐FAST): Add thoracic windows to look for pneumothorax.Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

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FASTPerisplenic view

trauma.org Rosen’s Emergency Medicine, 7th ed. 2009 

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FAST

Fluid in the subphrenic space and splenorenal recess can be detected. The image shown demonstrates blood (arrow) between the spleen (S) and diaphragm (D). 

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Diagnostic Peritoneal Lavage Largely replaced by FAST and CTIn blunt trauma, used to triage pt who is haemodynamically unstable and has multiple injuries with an equivocal FAST examination

Rosen’s Emergency Medicine, 7th ed. 2009 

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Diagnostic Peritoneal Lavage 1. attempt to aspirate free peritoneal blood 

>10 mL positive for intraperitoneal injury2. insert lavage catheter by seldinger, semiopen, or open3. lavage peritoneal cavity with salinePositive test:

RBC count > 100,000/mm3

Rosen’s Emergency Medicine, 7th ed. 2009 

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Page 45: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

CT abdomen with IV contrast

Noninvasive, highly accurate, easily identifies  and quantifies extent of injury, for stable patient only

A: Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen. 

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Splenic CT with Laceration & Blush

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Contrast Blush ‐ Spleen

• 216 Pts – 7 yrs• 26 Pts – Contrast blush on CT scan

• Lower HgB• More likely to need op (22% vs 4%)

• Not a definite indication for operation, but indicates subset of pts who have active bleeding and may need transfusion and/or operation

Blunt Splenic Injury

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AAST Splenic Injury Scale Spleen injury scale: (advance one grade for multiple injuries, up to grade III)

Grade I:  Hematoma: subcapsular, < 10% of surface area Laceration: capsular tear, < 1cm parenchymal depth

Grade II:  Hematoma: subcapsular, 10‐50% surface area; intraparenchymal, <5cm in 

diameter Laceration: 1‐3cm parenchymal depth which does not involve a trabecular vessel

Grade III: Hematoma: subcapsular, >50% surface area or expanding; ruptured subcapsular 

or parenchymal hematoma; intraparenchymal hematoma >5cm or expanding Laceration: >3cm parenchymal depth or involving trabecular vessesls

Grade IV:  Laceration: laceration involving segmental or hilar vessels producing major 

devascularization (>25% of spleen) Grade V:  Laceration: completely shattered spleen Vascular: hilar vascular injury which devascularizes spleen

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AAST Splenic Injury Scale

17‐yo boy injured on an ATV.  Grade I injury with subcapsular fluid occupying less than 10% of spleen’s surface area. 

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AAST Splenic Injury Scale

17‐yo girl injured in an MVC. Grade II injury with laceration involving less than 3 cm of parenchymal depth

Page 51: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

AAST Splenic Injury Scale

18‐yo boy injured playing football.  Lacerations involving more than 3 cm of parenchymal depth radiating from splenic hilum ‐grade III laceration

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AAST Splenic Injury Scale

16‐yo boy injured playing hockey.  Fractured spleen involving more than 25%, Grade IV splenic laceration

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AAST Splenic Injury Scale

12‐yo boy pedestrian struck by MV.  Fractured spleen with hilar devascularization. Grade V injury. 

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              Treatment

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Page 56: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

The unstable patient

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Stabilizing the patient

IVF (crystalloid, not colloid)TransfusionPRBC/plt/FFP

Recombinant activated factor VIIRewarming if hypothermicCorrection of metabolic abnormalitiesLow tidal volume ventilation recommended (4‐6 ml/kg)

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Damage Control Surgery

Patients with major exsanguinating injuries may not survive complex proceduresGOAL OF DCS: control hemorrhage, limit GI spillage, to prevent ischemia, infection, with abbreviated laparotomy followed by resuscitation prior to definitive repair

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Damage Control

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421‐430 

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Damage Control0. Initial resuscitation1. Control of hemorrhage and contaminationControl injured vasculature, bleeding solid organsAbdominal packingAutologous blood transfusion after collecting the blood in a cell saver which washes and collects RBCs.

2. back to the ICU for resuscitation3. Definitive repair of injuries4. Definitive closure of the abdomen

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Definitive repair

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Indications for Laparotomy Unstable vital signs with strongly suspected splenic injury 

Unstable patients with known or positive FAST/DPL

Unequivocal peritoneal irritation 

Minor splenic injury associated with other intra‐abdominal injury requiring laparotomy

Failure of conservative management 

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Haemodynamically stable patient

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Treatment Recommendations based on CT findingsGrade I and II injuries – admit for minimum of > 24 hours with serial exams and HCT – conservative management

Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 ‐6 hrs) for a minimum of 3 times and until stable 

Grade III injuries with moderate to large hemoperitoneum ‐Splenic Artery Angio‐embolization (SAE) ASAP with goal to be within 2 hours

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Size of HemoperitoneumSmall Hemoperitoneum ‐  perisplenic blood or blood in Morrison’s pouch

Moderate Hemoperitoneum – blood in one or both pericolic gutters

Large hemoperitoneum – blood in one or both gutters with additional blood in pelvis

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Grade IV injuries: Urgent SAE with goal to be within 2 hours

Grade V injuries: to the operating room in most circumstances

Grades I – IV: that show CT evidence of blush/pseudoaneurysm or extravasation – Urgent SAE or Laparotomy with goal to be within 2 hours 

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SPLENIC ARTERY EMBOLIZATION

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Initial Mangement of a Hemodymically Stable Patient with a Blunt Spleen Injury

CT scan with IV contrast

Angio‐Embolization (within 1‐2 hours)

Grade I & II can admit to Floor

Grade III

Moderate/Large hemoperitoneum

ICU/Step‐down unit*  ‐ q 4‐ 6 hr HCTs until stable X 3 

Dropping HCTs for 24 hours, or need to transfuse blood

Stable HCTs for 24 hours

Can mobilize patient, transfer to floor, and give diet pending other injuries

Consider the following options:OR, angio, Repeat CT scan 

No or Small hemoperitoneum

Blush, Extravisation, or Psuedoaneurysm

Floor patients: should be mobilized, diet advance and daily HCTs until stable for two days.Grade 1 and 2: minimum of 1 floor dayGrade 3‐5: minimum of 3 hospital daysSplenectomy patients require immunizations

Grade IV 

Grade V

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CONSERVATIVE MANAGEMENT

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Conservative managementIf there are no other injuries requiring laparotomy, isolated low grade splenic injury such as subcapsular haematoma of spleen may be managed successfully with conservative treatment:

ICUIV fluidsParenteral antibioticsBlood requisitioned and reservedIntensive monitoringClinically: Pulse, BP, respiration checked hourlyLab : serial haematocritRadiologically: serial USG abdomen – every 24 hrs.

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The patient kept under observation for 24‐48 hrs. 

If patient is stable, haematoma not increasing and shows signs of regression, conservative treatment may be continued.

If haematoma is expanding and there is evidence of intraperitoneal rupture, immediate laparotomy is to be  done. 

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SURGICAL MANAGEMENT•Splenectomy•Partial splenectomy•Spleen salvage

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Splenectomy Extensive laceration or Avulsion of splenic pedicle:

Page 75: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Steps of splenectomy

1. Mobilization of the spleen to the midline by division of the splenophrenic ligament superiorly and the splenocolic and splenorenal ligaments at the lower pole

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Page 77: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly
Page 78: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

2) The short gastric vessels are then divided between ligatures or clips 

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Spleen medialized and hilar dissection performed carefully with isolation of splenic vesselsSplenic hilum clamped en bloc and divided and doubly ligated proximally and once distally or splenic artery and vein are individually ligated.

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Page 81: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Splenic slice graftA portion of the spleen – 6 pieces of 40 * 40 * 3mm may be reimplanted within the leaf of greater omentum

Page 82: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Splenic slice graft

Page 83: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Splenic salvage Being practised from 1980, in view of development of Post splenectomy syndrome &OPSI, following splenectomy.

Splenorrhaphy ( repair of spleen)

The importance of spleen with regards to its immune function started the recent trend to conserve the spleen unless it is,

 extensively shattered and bleeding is uncontrollabe

Page 84: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Types of splenorrhaphy Topical methodsEnvelopment in meshPledgeted suture repair

Page 85: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Indications Small capsular tear: Bleeding controlled with local haemostatic agents like:Oxidized regenerated cellulose (surgicel) Fibrin glueElectrocauteryArgon beam coagulationApplication of thrombin soaked gelatin foam spongesIf it fails: – bleeding from the splenic tear controlled with a series of mattress sutures ‐ Pledgeted suture repair

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Page 87: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Polar tear managed with splenorrhaphy or partial splenectomy  followed by approximation of edges with a series of mattress sutures

Page 88: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Placement of the spleen in a mesh

Envelopment of the injured spleen in absorbable mesh, and to compress the splenic tissue and capsule back together, aided by purse–string sutures.

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Envelopment of the injured spleen in absorbable mesh

Page 90: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Envelopment of the injured spleen in absorbable mesh,

Page 91: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Role of Laparoscopy 

Most useful to evaluate penetrating wounds to thoracoabdominal region in stable pt

Not a substitute for open laparotomy. 

Rosen’s Emergency Medicine, 7th ed. 2009 

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92

Page 93: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly
Page 94: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly
Page 95: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Post operative complicationsImmediate: Bleeding from the remaining spleen

Early:Haematemesis Sub‐diaphragmatic abscessLeft basal atelactasisLeft pleural effusionThrombocytosisPancreatitis/abscess/fistula Gastric fistula

Late:Post splenectomy sepsis with S.pneumoniae, N.meningitides, 

H.influenzae, E.coliOPSI – opportunist post – splenectomy infection 

Page 96: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

 In‐Hospital Recommendations

DVT prophylaxisSequential compression devices upon admissionStable HCT for 48 ‐ 72 hours and no other contraindications‐ Strongly consider starting chemoprophylaxis (Low molecular weight heparin is preferred)

Page 97: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

Post operative prophylaxisPt requires vaccinations prior to dischargeStreptococcus pneumoniae

• Pneumovax 23Haemophilus influenzae type B

• Hib vaccineNeisseria meningitidis

• Quadravalent meningococcal/diphtheria conjugate

• Prophylactic antibiotics controversialMost centers use penicillin

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98

Follow up and discharge adviseAvoid contact sports for 2‐4 monthsImmediate treatment of infectionsPneumococcal  and meningococcal vaccinations every 5 yearsHib every ten yearsYearly infuenza vaccinations Regular followups (weekly) for those who were placed on conservative treatment. 

Page 99: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

    THANK YOU 

Page 100: Management of Splenic injury following blunt abdominal trauma · Discussion under the following headings Introduction to trauma Blunt injury abdomen ‐ Introduction Most commonly

REFERENCESBiffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. 

Curr Opin Crit Care 2010;16:609‐617 Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit 

Care Med. 2010 Sep;38(9 Suppl):S421‐30.Marx: Rosen’s Emergency Medicine, 7th ed. 2009 Mosby The effects of splenic artery embolization on nonoperative management of blunt 

splenic injury: a 16‐year experience.Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. J Trauma. 2009 

Sep;67(3):565‐72; discussion 571‐2.PMID: 19741401 [  Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of 

nonoperative success in patients of all ages.Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, Root HD, Pruitt 

BA Jr, Strodel WE.J Trauma. 2000 May;48(5):801‐5; discussion 805‐6.PMID: 10823522 [PubMed –

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 Improved outcome of adult blunt splenic injury: a cohort analysis.Rajani RR, Claridge JA, Yowler CJ, Patrick P, Wiant A, Summers JI, McDonald AA, Como JJ, 

Malangoni MA.Surgery. 2006 Oct;140(4):625‐31; discussion 631‐2.PMID: 17011910 Improved success in nonoperative management of blunt splenic injuries: embolization of splenic 

artery pseudoaneurysms.Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G, Kudsk KA, Pritchard FE.J Trauma. 1998 Jun;44(6):1008‐13; discussion 1013‐5.PMID: 9637156  Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic 

injury.Liu PP, Lee WC, Cheng YF, Hsieh PM, Hsieh YM, Tan BL, Chen FC, Huang TC, Tung CC.J Trauma. 2004 Apr;56(4):768‐72; discussion 773.PMID: 15187739 Blunt splenic injury in adults: Multi‐institutional Study of the Eastern Association for the 

Surgery of Trauma.Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, Croce M, Enderson BL, 

Morris JA, Shatz D, Meredith JW, Ochoa JB, Fakhry SM, Cushman JG, Minei JP, McCarthy M, Luchette FA, Townsend R, Tinkoff G, Block EF, Ross S, Frykberg ER, Bell RM, Davis F 3rd, Weireter L, Shapiro MB. J Trauma. 2000 Aug;49(2):177‐87; discussion 187‐9.PMID: 10963527 [PubMed ‐ indexed for MEDLINE]


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