Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Rupture of Spleen, Traumatic


Related Terms

  • Splenic Rupture

Differential Diagnosis

Specialists

  • Critical Care Surgeon
  • General Surgeon

Comorbid Conditions

Factors Influencing Duration

The factors that influence disability include severity of the injury to the spleen, job requirements, and whether treatment was operative or nonoperative, whether the individual had other traumatic injuries acquired concomitant with injury to the spleen, and whether the individual had underlying medical conditions such as anemia or bleeding disorders.

Medical Codes

ICD-9-CM:
865.04 - Spleen Injury without Mention of Open Wound into Cavity, Massive Parenchyma Disruption
865.14 - Spleen Injury with Open Wound into Cavity, Massive Parenchyma Disruption

Overview

A ruptured spleen occurs when the organ or its blood supply has been disrupted by penetrating trauma, nonpenetrating trauma, operative trauma, or by a spontaneous event.

The spleen is the most common intra-abdominal organ injured in blunt trauma (often associated with automobile accidents or body-contact sports) and is frequently injured by penetrating trauma (gunshot, knife wound). Splenic ruptures can occur acutely (such as after an automobile accident) or may be delayed (as from a very slow bleed). Surgeons classify splenic ruptures by the amount of injury to the organ, with class I having the least amount of damage and class V the most.

Conditions that cause splenic enlargement (splenomegaly), such as lymphoma or mononucleosis, make the spleen more fragile and susceptible to spontaneous rupture. The spleen is vulnerable to injury during operative procedures in the upper abdomen. Operations on the stomach, hiatus, vagus nerves, pancreas, left kidney and adrenal gland, and transverse and descending colon carry the risk of splenic injury.

Injuries to the body of the spleen that do not disrupt major vessels cause an initial blood loss of about 500 ml that ceases spontaneously without signs of abdominal distention or shock. These types of injuries, however, have the potential to cause rupture at a time remote from the injury and account for the phenomenon of delayed rupture of the spleen.

Incidence and Prevalence: Motor vehicle accidents are the most common cause of injury to the spleen. Splenic injury occurs in 25% to 30% of motor vehicle accidents in which blunt abdominal trauma is diagnosed (Klepac).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Because injury to the spleen often occurs from automobile accidents, gunshot wounds, and contact sports, the incidence of splenic rupture is highest among individuals aged 15 to 35. Men are slightly more likely to experience spleen injuries than women.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report blunt upper abdominal trauma, such as that inflicted from a steering wheel or the handlebars of a bicycle during an impact accident. In some cases, individuals may report penetrating trauma (knife or gunshot wound) to the left chest or left upper abdomen. At times, individuals also complain of left shoulder or neck pain. They may report feeling lightheaded or dizzy.

Physical exam: Rupture of the protective outer layer of the spleen (splenic capsule) may cause significant bleeding into the abdomen and result in associated signs of abdominal distention and hemorrhagic shock. Splenic injury resulting in blood in the abdomen produces characteristic signs and symptoms. Generalized left upper abdominal pain occurs in approximately one-third of those with splenic injury. Palpation to the left upper abdomen may cause referred pain to the tip of the left shoulder (Kehr's sign) that suggests splenic injury. Palpable rib fractures may be felt on the left side. Any penetrating wounds to the abdomen or chest are potential sources of splenic injury.

Signs of hemorrhagic shock such as increased pulse, decreased blood pressure, a sudden drop in blood pressure when positioned upright from a supine position (orthostatic hypotension), and cool skin may be associated with more significant acute injuries.

Tests: Tests may include a complete blood count (CBC) to determine the presence and degree of blood loss. Individuals with splenic trauma usually have hemoglobin/hematocrit values that are 10% to 30% below normal. A needle sampling of the peritoneal fluid or diagnostic peritoneal lavage looks for evidence of internal bleeding and continues to be an important adjunct to the diagnosis of abdominal injuries, including injuries to the spleen.

A CT scan of the abdomen and chest with an intravenous injection contrast medium is usually the preferred initial diagnostic test. The scan may show the presence and approximate quantity of hemorrhage of the spleen and other adjacent structures. However, CT scan has some limitations, especially if the injured individual will not stay still during scanning. X-rays may be used to supplement the CT scan, as may ultrasound studies. In the case of a delayed rupture, x-rays of the splenic vessels (splenic arteriograms) are usually taken.

Individuals who present with hemorrhagic shock usually have immediate exploratory surgery (laparotomy) to determine if the bleeding can be stopped or if the spleen should be removed.

Source: Medical Disability Advisor



Treatment

Management of shock is of prime importance in the treatment of an individual with a ruptured spleen. Depending on the mechanism of injury, management will vary. Those individuals with sustained multiple injuries may need emergency interventions to maintain their airway and provide ventilation. Any injuries, including a ruptured spleen, associated with low blood pressure and rapid pulse (shock) need to be treated with rapid fluid replacement and possibly blood transfusion. If shock is severe, a large vein (central vein, internal carotid, brachial, or femoral vein) is often catheterized to administer large volumes of fluid rapidly. Individuals with signs of hemorrhagic shock are treated with a laparotomy to identify and control the source(s) of bleeding.

In recent years, treatment of spleen injuries has evolved toward splenic repair and preservation because of the spleen's important role in immunity and a better understanding of complications that can arise from splenectomy later in life. Partial splenectomy or splenic repairs are being done with greater frequency and success. Currently only about 30% of patients are treated with surgery (Townsend 339). Immunizations against pneumococcal, meningococcal, and Haemophilus influenzae are recommended prior to splenic operations to protect the individual from postsplenectomy infections and sepsis. These immunizations are generally repeated every 5 years following splenic surgery to extend the protection.

About three-quarters of individuals whose vital signs are stable are treated nonoperatively. The possibility of delayed rupture is the greatest risk associated with nonoperative treatment. Nonoperative management may require significant transfusions, repeated CT scans and hematocrits, and close observation for up to 2 weeks, including an initial period of observation in intensive care. Delayed ruptures of the spleen typically occur within 2 weeks. Approximately 10% of those individuals initially treated nonoperatively eventually require surgery (Townsend 340).

Source: Medical Disability Advisor



Prognosis

The outcomes for both nonoperative and operative management of splenic ruptures are good when treatment is received promptly. Recovery without surgery is greater than 90% for individuals treated nonoperatively (Upadhyay 321). Mortality rates associated with splenic injury range from 10% to 25% and are usually due to associated injury to other organs and substantial blood loss (Carlin 232).

Source: Medical Disability Advisor



Complications

Nonoperative management of splenic trauma poses the potential for missing concomitant abdominal injuries and may result in delayed splenic rupture.

Overwhelming sepsis is the most common and most serious complication of splenectomy and may result in death. Individuals undergoing splenectomy may experience immune system complications in the future despite recovery from surgery.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If the individual undergoes surgery, assignment of light sedentary duties at work may be needed until the surgical site fully heals or medical clearance is obtained from the surgeon. Those who have had a laparoscopic splenectomy may return to work and usual activities sooner, often within a week. If individuals are medically observed, they may need light sedentary duty for 2 to 4 weeks after return to work, based on the severity of the splenic rupture.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has individual experienced recent blunt trauma (from a steering wheel or bicycle handlebars or from participating in contact sports) or penetrating trauma (gunshot or knife wound)?
  • Does individual have a history of an enlarged spleen (splenomegaly)?
  • Has individual undergone recent surgery that may have caused splenic rupture?
  • Is individual experiencing bleeding into the abdomen? Was bleeding severe enough to cause hemorrhagic shock?
  • Is individual experiencing a delayed rupture from a previous injury?
  • Does individual demonstrate signs of a bleeding disorder, such as prolonged bleeding or bleeding from gums, wounds, or urinary tract?
  • Was a recent CBC done to rule out infection or hemorrhage? Was a chest x-ray taken to rule out lung complications? Does peritoneal fluid, CT scan, or ultrasound reveal the presence of bleeding?
  • If this is a delayed rupture, was a recent splenic arteriogram obtained?

Regarding treatment:

  • Were emergency interventions needed to maintain the airway and provide ventilation? Were IV fluids or blood transfusions required to combat shock?
  • If signs of hemorrhagic shock are present, was a laparotomy done to identify and control the source(s) of bleeding?
  • Was surgery required for repair or partial removal of the spleen (partial splenectomy)?
  • Did individual receive appropriate vaccinations prior to surgery, such as pneumococcal, meningococcal, and Haemophilus influenzae type B conjugate vaccines?

Regarding prognosis:

  • Did individual receive nonoperative treatment or require surgical intervention?
  • Could individual have a delayed rupture?
  • Did individual experience hemorrhagic shock? Did individual develop shock-related bleeding disorder (disseminated intravascular coagulation or DIC)?
  • Have postsurgical complications arisen, particularly infection?
  • Did individual develop lung problems?
  • What is the treatment plan for the complication, and what is the expected outcome of this treatment?

Source: Medical Disability Advisor



References

Cited

Carlin, A. M., et al. "Factors Affecting the Outcome of Patients With Splenic Trauma." American Surgeon 68 3 (2002): 232-239.

Klepac, Steven R., and Evan J. Samett. "Spleen, Trauma." eMedicine. Eds. Neela Lamki, et al. 21 Oct. 2002. Medscape. 29 Oct. 2004 <http://emedicine.com/radio/topic645.htm>.

Townsend, C. M., and D. C. Sabiston, eds. Sabiston Textbook of Surgery. 16th ed. Philadelphia: W.B. Saunders, 2001.

Upadhyaya, P. "Conservative Management of Splenic Trauma: History and Current Trends." Pediatric Surgery International 9 (2003): 617-627.

Source: Medical Disability Advisor






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