Transcript Asplenism in the Emergency Department

Asplenism in the
Emergency Department
Jim P. Getzinger, MD
William Beaumont Hospital
Royal Oak, MI
Splenic Trauma in the ED
• Classification of injury
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Contusions
Capsular tears
Hematomas – subcapsular or intraparenchymal
Lacerations
Fracture
Puncture wounds
Laceration of vessels supplying hilum
Avulsion from vascular pedicle
• Classification based on time
– Acute
– Delayed
– Occult
Injury Grade
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GR
I
I
II
II
II
INJURY
Hematoma
Laceration
Hematoma
Hematoma
Laceration
POSITION
Subcapsular
Capsular tear
Subcapsular
Intraparenchymal
Capsular tear
• III
Hematoma
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Hematoma
Hematoma
Laceration
Hematoma
Laceration
Laceration
Laceration
Subcapsular or
Intraparenchymal
Subcapsular
Intraparenchymal
Parenchymal
Intraparenchymal
III
III
III
IV
IV
V
V
Hilar region
DESCRIPTION
Nonexpanding
Nonbleeding
Nonexpanding
Nonexpanding
Bleeding
w/o Trabecular involvement
Expanding
SIZE
< 10%
< 1cm
10-50%
< 2 cm
Bleeding
> 50%
> 2 cm
> 3 cm
Involves trabecular vessels
Ruptured and Bleeding
Involves hilar vessels
Completely shattered
Completely devascularized
1-3 cm
The Spleen
Total splenectomy will be required in those with a hilar injury, massive
subcapsular hematoma, fragmentation, or splenic avulsion.
Asplenism
• Asplenic patients are at lifelong risk for serious
infections, especially with encapsulated organisms such
as Strep. pneumoniae, H. influenzae and N. meningitidis.
• With the growing concern about antibiotic-resistant
pneumococci, the appropriate detection and treatment of
asplenic and hyposplenic patients has become
increasingly important.
Post-Splenectomy Sepsis
• 1930’s – Early post-surgical studies
showed no increase in sepsis after
splenectomy
• 1952 – King & Schumacker describe 5
infants post-splenectomy for congenital
spherocytosis that die of fulminant sepsis.
Clinical Features
• Initial symptoms of overwhelming post-splenectomy
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infection are often mild, with an influenza-like
presentation that includes fever, malaise, myalgias,
headache, vomiting, diarrhea and abdominal pain.
Overwhelming Postsplenectomy infection (OPSI) first
coined by Diamond in 1969
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Fulminant course
Freq. Lack of septic focus
Bacteremia, pneumonia or meningitis
Consumptive coagulopathy, adrenal hemorrhage (WaterhouseFriderichsen syndrome) leading to shock and coma.
– Large numbers of organisms in blood (>1M/ml)
Incidence
• Problems
– Rare event – Need large patient populations
– Infection can be years later – long f/ups req.
– Incidence varies with age, underlying disease
• S/P Trauma – infection 3.3 / 100 pt-yrs
• S/P Cancer – infection 16.6 / 100 pt-yrs
Incidence
• O’Neal & McDonald 1981
– 256 Adult splenectomies f/u 45 mos
– 2.7% developed sepsis
– Estimated risk of death at 540 times normal
population.
Incidence
• Chaik and McCabe, 1985
– 776 splenectomies over mean 8.4 yrs
– Incidence OPSI 3.7% children, 0.3% Adult
• Hays et al 1986
– 234 lymphoma pts, splen. Staging, f/u 3.8 yrs
– 1.7% bacteremia (83% vac / 74% abx)
Incidence
• Ellison & Fabri, 1983
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Multistudy review of 3430 cases
Peds 4% sepsis (1.8% mortality)
Adult 1.9% sepsis (1.1% mortality)
Est. risk – 40x for sepsis & 17x for death
20% cases in first 6mo, 60% in first 2 yrs
• Overall incidence 0.9% - 6.9%
• Mortality may exceed 50%
Risk Factors
• Underlying condition
– Defective cellular immunity
• Hodgkins’ disease, hypogammaglobulinemia
– Chemotherapy, radiation
– Bone Marrow transplantation
• Age Group
– Children >> Adults
– Children often have lower antibodies against encapsulated org.
• Time after splenectomy
– Greatest in first 2 yrs (50%-70%), but risk is lifelong
Causative Organisms
• Pneumococcus - > 50%
• H. influenza, Meningococcus, Strep Pyog.
• Less common
– Pseudomonas
– Capnocytophaga canimorsus (animal bites)
– Malaria
– Babesiosis
– Viruses – CMV, herpes, influenza
Mechanisms
• Phagocytosis and clearance of bacteria/protozoa is
impaired.
• Spleen is site of production of specific antibodies
• Impaired immune response
– Encapsulated orgs must be opsonised before they can be
phagocytosed. Production of opsonins is impaired.
• Spleen controls circulating B cells capable of
differentiating into antipneumococcal capsular
polysaccharide antibody-secreting B cells.
Detection
• Most patients with trauma will know
– Some older patients may not recall
• Hiatal hernia surgery, partial gastric resection PUD
– Careful physical examination for scars
– Ask about Diseases
Medical Conditions That May Be
Associated with Hyposplenism
Congenital
Isolated congenital anomaly
Congenital cyanotic heart
disease
Gastrointestinal
Celiac disease with or
without dermatitis
herpetiformis*
Inflammatory bowel disease
(especially ulcerative colitis)
Whipple’s disease
Intestinal lymphangiectasia
Liver disease
Cirrhosis with or without
portal hypertension*
Chronic active hepatitis
Acute alcoholism
Hematologic
Sickle cell disease*
Other hemoglobinopathies
(Hb S-C disease, Hb S-E
disease, Hb S–b-thalassemia)
Primary thrombocythemia
Fanconi’s syndrome
Malignant histiocytosis
Autoimmune
Vasculitis (may be associated
with splenic infarct)*
Systemic lupus
erythematosus
or discoid lupus*
Rheumatoid arthritis
Sjögren’s syndrome
Graves’ disease
Infiltrative
Thorium dioxide administration
Amyloidosis
Sarcoidosis
Vascular
Splenic artery occlusion
Splenic vein thrombosis
Celiac artery thrombosis
Miscellaneous
HIV infection
Graft-versus-host disease
Bone marrow transplantation*
Total parenteral nutrition
High-dose steroid therapy
Splenic irradiation (Hodgkin’s
disease)*
Peripheral Blood Smear
Management of Patients at Risk
• Vaccination
– Give Pneumococcal, Meningococcal, and
Haemophilus b conjugate vaccine at least 14
days before surgery (or as soon as possible)
– repeat PneumoVax every 3-5 yrs depending
on age & medical condition
Pneumococcal Vaccine
• Developed 1983
– 23 serotypes (approx 90%)
– Ideal conditions – fails 20-30% of recipients
– Give before splenectomy if possible
• Immunogenicity reduced after splenectomy or
during chemo.
– Age > 10 – revaccinate every 5 yrs
– Age < 10 – revaccinate every 3 yrs
Antibiotics - Prophylaxis
• Recommended for children, especially for first 2
yrs after splenectomy.
– Augmentin, Bactrim, Cefuroxime
• At least 5 yrs of prophylaxis
• Adults – recommended standby antibiotics
– Taken at first sign of infection
– Still should seek medical attention
• Endemic Malaria areas
– Mefloquine, Doxycycline or chloroquine+proguanil
Studies
• Do NOT delay ABX therapy for labs
• Labs
– Hematologic profile, lytes, creatinine, glucose
– Peripheral blood smear, buffy-coat prep
– Blood cultures, consider CSF cx
• Chest Xray
Buffy-Coat
Empiric Antibiotic Therapy
• Initial
– Third Generation Cephalosporin
– With or without Vancomycin
• Specific Treatment based on organism
– Add ciprofloxacin or gentamicin if GI/Urine
source suspected
– Penicillin for C. canimorsus
IV Drug Treatment
Drug
Adult Dosage
Pediatric Dose
Cefotaxime
2g IV q8hr
25-50mg/kg IV
q6hr
Ceftriaxone
2g IV q12-24hr
50 mg/kg IV q12hr
+/- Gentamicin
OR
+/- Ciprofloxacin
5-7 mg/kg q24hr
2.5mg/kg IV q8hr
400mg IV q12hr
*do not use*
+/- Vancomycin
(when PCN Resist)
1-1.5g IV q12hr
30mg/kg IV q12hr
(If GI/Urine Src susp)
Education
• Patients should be made aware of increased risk of
serious infection.
• Wear MedicAlert bracelet or necklace
• Notify their doctor immediately of any acute febrile
illness (esp. if assoc with rigors or systemic symptoms)
• Seek prompt treatment even after minor dog bite or
other animal bite.
In closing:
• Consider OPSI in patients with unexplained
hypotension, rapid onset, failed outpt abx. Look
for scars, history!, recent travel (Babesia,
malaria)
• Start ABX as soon as possible. Be aggressive!
– 3rd Gen. Cephalasporin With/Without Vanco
• Don’t let GI symptoms divert diagnosis
Final Thoughts
• Always check your footing/ladder carefully
• Make sure someone knows you’re on the roof
• If they hear a yell, and a thud, call 911.
• When all else fails, hire someone to put up your
holiday lights!