Dr Eanna Mac Suibhne
Dr Hector Thomson
Dr David McCreary
As the decades have rolled by, the management of splenic trauma has changed significantly. The long-practiced tradition of removing the spleen for the slightest insult has been consigned to the history books, alongside similarly traumatic memories like the Oasis break up (come on Noel!).
So what has changed, why the change, and what does it matter?
Firstly, splenic injuries are common, with spleens considered as the most injured intra-abdominal organ, accounting for up to 45% of all visceral injuries(1). The spleen is thought to be injuried in trauma in one of two ways, either by deceleration injury with resultant shearing at relatively fixed points or by impacting against the lower left-sided ribs resulting in a direct crushing or compressive force(2). In either event, the resulting parenchymal and/or vascular injuries can cause significant haemodynamic instability.
Going back a bit, a good bit, to the time of Aristotle in fact, total splenectomies were a common and routine surgical practice, as it was thought the spleen was an unnecessary organ. As the centuries went by, other reasons for splenectomy ranged from curing melancholy, treating suicidal tendencies to improving the speed of marathon runners(3).
In 1648, the first total splenectomy for trauma was performed in a patient who sustained a laceration of the spleen via a left flank wound. From that point until 1971, routine splenectomy used to be the ‘go to’ treatment for splenic trauma. At the time, non-operative management (NOM) was thought to carry a mortality of 90 to 100%(4).
In the past three decades, the management of splenic injuries has shifted towards preservation of the spleen. This is in recognition of its vital functions in terms of immunological function. NOM now dominates management strategies, with operative intervention now only required in haemodynamically unstable situations.
Non-operative strategies range from close monitoring to splenic artery angiography and embolisation. In fact, success rates of 95.8% with a NOM strategy have been reported, largely due to the success of splenic artery embolisation in addressing significant vascular injuries(5).
From an emergency medicine point of view, a patient presenting with findings consistent with blunt abdominal trauma will most likely have been involved in a mechanism of injury warranting CT pan scan. In the trauma bay though, pre scan, POCUS can help forecast the course of resuscitation.
So, what to look for on ultrasound:
- The presence of free fluid, particularly in the upper abdomen, and as always with FAST scanning, if you don’t see it, it doesn’t rule it out.
- There may be disruption to the splenic echotexture indicating laceration; you may identify a haematoma, represented by hypoechoic regions within the body of the spleen.
CT scan is the modality of choice when assessing the spleen and is considered the gold standard in trauma with sensitivity and specificity ranging from 96 to 100%(6) for splenic injuries. Injuries to the parenchyma are seen best through the portal venous phase while the arterial phase is best for assessing vascular injuries. Parenchymal lacerations cannot be appreciated with the “zebra/psychedelic” appearance that occurs with the arterial phase. Pseudoaneurysms and AV fistulas can be misinterpreted as active haemorrhage on initial scanning but do not increase in size in delayed phases.
The American Association for the Surgery of Trauma (AAST) standardised the reporting of splenic injuries by developing a grading system based on the anatomic disruption of the spleen, as shown on CT scans or during laparotomy(7). Have a look at the grading here or see the excellent Radiopaedia summary diagram, below:
Case courtesy of Dr Sachintha Hapugoda, Radiopaedia.org, rID: 51434
Ranging from 1 to 5, this classification system stratifies injuries in terms of size and extent of any haematomas, lacerations, and vascular involvement. While this system describes the injury, no recommendation is made in their specific management. Centres will adopt their own thresholds for intervention regarding observation and angioembolisation.
In 2017, the World Society for Emergency Surgery (WSES) concluded that hemodynamic status, anatomic derangement, and associated injuries should all factor into the management of this injury, with the primary goal of restoring homeostasis and normal pathophysiology(8).
WSES has proposed that injuries should be grouped into minor, moderate, and severe. Lower grade AAST lesions, from grades I to III for example, have been reclassified as minor or moderate. Higher–grade lesions from AAST IV to V, can be treated with a non-operative strategy where there is haemodynamic stability whereas minor lesions, with compromised haemodynamics, should be treated operatively. This supports the creation of a classification system accounting for anatomic derangement and haemodynamic status. This classification, as detailed here, stratifies the four WSES classes, I to IV, based on AAST grading and haemodynamic status, with separate consideration given to the appropriateness of CT in each class and recommended first-line treatment.
Considering this system, WSES have adopted a colourful and streamlined algorithm as a decision aid in the management for these injuries which you can see here.
🤓 Editor’s Comment: Apologies to the authors of the above-linked flow chart but your power-point flow chart creation skills weren’t up to scratch and I would have lost sleep if I hadn’t made it look neater, see below.
Adapted from this figure by Coccolini et al.
In Emergency Medicine terms, that’s what we are here for. When presented with an unstable patient with a positive EFAST, CT should be bypassed, and the patient should progress to laparotomy +/- splenectomy/splenic salvage. Do not pass Go, do not collect $200.
With a patient who is haemodynamically stable, non-operative strategies can be pursued, with progression to operative management where angioembolisation or non-operative management (NOM) has failed, demonstrated by deteriorating clinical or haemodynamic status. With respect to NOM, close observation involves HDU level care with tight haemodynamic monitoring and regular examination. At the Alfred, indications for Angio are AAST Grade IV or V splenic injury which include the presence of vascular injury.
When anticipating which patient might fail NOM, we should have a higher level of suspicion in patients aged 55 years or greater, those with a high injury severity score and those displaying moderate to severe splenic injuries. Patients who are anticoagulated also warrant close monitoring. This being said, in a high-volume tertiary referral centre, NOM has a success rate near 90%(9).
So, when your next splenic trauma comes in, have this in the back of your mind!
Peer-Reviewer Comments: The Alfred Perspective
As Eanna has mentioned, centres will adopt their own thresholds for intervention regarding observation and angioembolisation. Below is the flowchart from the Alfred Trauma Manual. In this case stable is defined as “any airway, respiratory, circulatory, neurological or behavioural threat to patient or staff safety is controlled.”
Increasingly, the radiologists are willing to take patients with a lower blood pressure as long as a critical care physician is available to escort them. It isn’t unusual to take a high grade spleen up while transfusing.
Currently 85% of all patients admitted to the Alfred with splenic injuries, are managed non-operatively. Of these patients, 38% undergo splenic artery embolization, and 3.0% of patients go on to require splenectomy after initial embolisation. The SPLEEN-IN study from 2009-2019 analysed 232 patients who underwent embolization. There were 13 complications (5.6%) consisting of re-bleed (3.9%), infarction (1.3%), and access site haematoma (0.43%). Importantly angiography in patients with grade III injuries identified 18 occult vascular injuries not identified at initial CT.
The pictures from their paper are also quite nice:
Catheter angiography from the splenic artery showing high grade parenchymal injury a successfully treated with proximal embolization b and patient with infarct after proximal embolization (arrow) c
- Hildebrand DR. Modern management of splenic trauma. BMJ. 2014;348.
- Dreizin D., Munera F.: Blunt polytrauma: evaluation with 64-section whole-body CT angiography. RadioGraphics 2012; 32: pp. 609-631
- Meade RH (1968) Surgery of spleen. In: An Introduction to the History of General Surgery. Saunders, Philadelphia London Toronto, pp 256–260
- Upadhyaya P. Conservative management of splenic trauma: history and current trends. Pediatr Surg Int. 2003 Nov;19(9-10):617-27. doi: 10.1007/s00383-003-0972-y. Epub 2003 Nov 12. PMID: 14614630.
- Shi. H et al, CT of blunt splenic injuries: what the trauma team wants to know from the radiologist. Clinical Radiology, 2019-12-01, Volume 74, Issue 12, Pages 903-911
- Carr JA et al, Correlation of operative and pathological injury grade with computed tomographic grade in the failed nonoperative management of blunt splenic trauma. Eur J Trauma Emerg Surg. 2012 Aug; 38(4):433-8.
- Moore EE et al. Organ injury scaling: spleen and liver (1994 revision).J Trauma. 1995 Mar;38(3):323-4
- Coccolini F, et al. Splenic trauma: WSES classification and guidelines for adult and paediatric patients. World J Emerg Surg. 2017;12:40. Published 2017 Aug 18. doi:10.1186/s13017-017-0151-4
- Smith J, Armen S, Cook CH, Martin LC, Blunt splenic injuries: have we watched long enough? J Trauma. 2008 Mar; 64(3):656-63; discussion 663-5.
Eanna Mac Suibhne
Eanna is an Irish-trained Emergency physician whose interests broadly include trauma, toxicology and sports injury management. The search of experiencing working in an MTC has resulted in sticks being upped and his recent move to Melbourne. The freely available great coffee was a happy coincidence.