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Q1: NOM vs Surgery (3 min)
"When would you choose non-operative management over surgery for a splenic injury?"
- EAST: NOM is the treatment of choice in haemodynamically stable patients, irrespective of grade, age, or associated injuries, but only where monitoring, serial examination, and an operating room for urgent laparotomy are available
- Instability and peritonitis still warrant emergent operative intervention
- WSES adult instability includes admission SBP under 90 mmHg (with vasoconstriction/altered consciousness) or the WSES packed-red-cell transfusion threshold in the first 24 hours — not an unsourced "under 2 units" cutoff
- Arterial blush in a stable patient: SAE first-line, irrespective of grade (Podda)
- Requarth: 68.4% of 10,157 adults managed non-operatively; overall NOM failure 8.3% (6.7–10.2)
- Surgery for: instability, peritonitis, failed NOM, associated hollow viscus injury
Q2: AAST Grading (3 min)
"Describe the AAST splenic injury grading system."
Parenchymal cuts as reprinted by WSES Table 1 (Kozar 2018 has no PubMed abstract):
- Grade I: subcapsular haematoma under 10% or capsular tear under 1 cm
- Grade II: subcapsular 10–50%, intraparenchymal under 5 cm, or laceration 1–3 cm not involving a parenchymal vessel
- Grade III: subcapsular over 50%/expanding/ruptured, intraparenchymal over 5 cm, or laceration over 3 cm or involving trabecular vessels
- Grade IV: segmental/hilar vessels producing major devascularisation (over 25%)
- Grade V: completely shattered spleen, or hilar injury that devascularises the spleen
- 2018 (Shi/Morell): active bleed, pseudoaneurysm or AV fistula indicates at least Grade IV; Grade V includes active bleeding extending beyond the spleen into the peritoneum
- Grade is not the operability switch — physiology is (EAST; Morell)
Q3: OPSI (3 min)
"What is OPSI and how do you prevent it?"
- OPSI = overwhelming post-splenectomy infection (fulminant sepsis, meningitis or pneumonia)
- WSES: incidence 0.5–2%; mortality 30–70%; most deaths within 24 h; pneumococcus ~50% of cases
- Davidson: 0.23–0.42% per year, lifetime risk 5%; mortality 38–69%; pneumococcus 50–90% of blood-culture isolates
- Hansen: encapsulated organisms (pneumococcus, Hib, meningococcus); risk greatest in infants and young children
- Prevention: PCV13 then PPSV23 at least 8 weeks later (ACIP); meningococcal/Hib; annual influenza; start vaccination no sooner than 14 days after trauma splenectomy (WSES)
- Standby amoxycillin (WSES adult starting regimen) or a fluoroquinolone if beta-lactam allergic; alert bracelet; fever = immediate parenteral antibiotics and ICU (Davidson)
- Duration of daily prophylaxis is controversial (WSES); Gaston penicillin OR 0.37 is SCA children under 3 years, not trauma splenectomy
Q4: Surgical Technique (2 min)
"Describe the steps of an emergency splenectomy."
- Midline laparotomy
- Evacuate blood and clots
- Pack all four quadrants; remove systematically from least to most likely bleeding
- Mobilise spleen: divide splenocolic, gastrosplenic (short gastrics), splenophrenic, splenorenal ligaments (conventional operative sequence)
- Deliver spleen into wound
- Individual vessel ligation at the hilum (avoid mass ligation — pancreatic tail)
- Inspect tail of pancreas for injury — drain if concerned
- Search for accessory spleens (reported incidence 10–30%)
- Partial splenectomy can preserve red-cell pitting but has not provided total protection against overwhelming infection (Hansen) — still vaccinate
Q5: Complications (2 min)
"What are the complications of splenectomy?"
- Early: rebleeding; SAE life-threatening complications ~20.4% (primary success 90.1%; surgery after SAE 6.4% — Rong); pancreatic fistula; atelectasis; splanchnic vein thrombosis 24.6% after splenectomy for cirrhosis vs 11.7% after SAE (Wu)
- Late: OPSI (WSES 0.5–2%, mortality 30–70%); Bisharat overall post-splenectomy infection 3.2% with 1.4% death across mixed indications; highest in thalassaemia major (8.2%/5.1%)
- LMWH and warfarin reduce portal-vein-system thrombosis after cirrhotic splenectomy without increased bleeding; optimal warfarin use 6 months (Liao)
- All post-splenectomy patients need the infection-prevention bundle