II. Grading: AAST CT Grade for Splenic Injury

  1. Precautions
    1. May not accurately correlate with surgical findings
    2. Does not consistently predict the need for surgical intervention
  2. Grade 1
    1. Subcapsular hematoma <10% surface area OR
    2. Splenic Laceration <1 cm depth into parenchyma
  3. Grade 2
    1. Subcapsular hematoma 10-50% surface area OR
    2. Splenic Laceration 1-3 cm depth into parenchyma (not involving trabecular vessels)
  4. Grade 3
    1. Subcapsular hematoma >50% surface area or expanding OR
    2. Ruptured subcapsular or parenchymal hematoma OR
    3. Intraparenchymal hematoma >5 cm or expanding OR
    4. Splenic Laceration >3 cm depth into parenchyma OR
    5. Trabecular vessel involvement
  5. Grade 4
    1. Splenic Laceration involving segmental or hilar vessels with >25% splenic devascularization
  6. Grade 5
    1. Shattered Spleen OR
    2. Hilar vessel injury with complete splenic devascularization
  7. References
    1. Tinkoff (2008) J Am Coll Surg 207:646 [PubMed]

III. Management: Surgery

  1. Indications: Emergent Surgery (to identify and control intraperioneal Hemorrhage)
    1. Hemodynamically unstable Trauma patient AND
    2. Positive FAST Scan or DPL
  2. Indications: Other findings despite hemodynamic stability
    1. High grade Splenic Injury (Grade 4 and especially Grade 5)
    2. Age over 55 years old
    3. Other serious comorbid injuries or illness and unlikely to tolerate Hypotension
    4. Generalized peritonitis
    5. Evidence for other intraabdominal injuries
    6. Refusal of Blood Products in the presence of severe Anemia (e.g. Jehovah Witness)
    7. Unreliable patient for serial abdominal examinations (e.g. Altered Level of Consciousness)
  3. Indications: Other findings that may be amenable to splenic embolization as an alternative instead of surgery
    1. Large volume hemoperitoneum
    2. Active radiocontrast extravasation

IV. Management: Splenic Embolization

  1. Contraindications
    1. Hemodyanmic instability
    2. Surgical indications as above
  2. Indications
    1. Abdominal CT with contrast extravasation or blush
    2. Intraparenchymal pseudoaneurysm
    3. Large volume hemoperitoneum
  3. Protocol
    1. Intervention radiology cannulates and embolizes via the Celiac Artery
      1. Access via brachial or femoral artery to the abdominal aorta
    2. Continue with nonoperative observation as below

V. Management: Nonoperative

  1. Contraindications
    1. Close medical and nursing monitoring not available
    2. Urgent or emergent surgical or embolization not available
    3. Hemodynamic instability
    4. Surgical interventions above
  2. Protocol
    1. Admit to intensive care unit (or other highly monitored hospital setting)
    2. Serial Hemoglobin every 6 hours for the first 24 hours
    3. Nothing by mouth for the first 24 hours
      1. May then eat when emergent surgery is unlikely
      2. Must first demonstrate stable Vital Signs and serial Hemoglobins
    4. Consider repeat Abdominal CT imaging
      1. Hemoglobin decrease (via trend or significant drop)
      2. Increased Abdominal Pain or left Shoulder Pain
      3. Fever
      4. Unreliable abdominal examination (e.g. Altered Level of Consciousness)
      5. Consider at 24-48 hours if high grade Splenic Injury (Grade 3 or higher)
    5. Indications for surgical intervention
      1. Continued Hemoglobin decrease or need for repeated Blood Transfusion
      2. Hemodynamic instability (e.g. Hypotension, persistent Sinus Tachycardia)
      3. Repeat imaging indicates further intervention
  3. Safety
    1. Initial non-operative management in stable patients with Grade 4-5 splenic Lacerations appears safe
      1. Scarborough (2016) J Am Coll Surg 223(2): 249-58 +PMID: 27112125 [PubMed]

VI. Management: Follow-up

  1. See Asplenia

VII. References

  1. Maung in Frankel (2014) Management of Splenic Injury in the Adult Trauma Patient, UpToDate, Wolters Kluwer
  2. Hildebrand (2014) BMJ 348:g1864 [PubMed]
  3. Stein (2006) J Intensive Care Med 21:296-304 [PubMed]

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Related Studies (from Trip Database) Open in New Window

Ontology: Splenic Rupture (C0038000)

Concepts Injury or Poisoning (T037)
MSH D013161
SnomedCT 210196007, 262817009, 234506007
English Rupture, Splenic, Ruptures, Splenic, Splenic Rupture, Splenic Ruptures, Ruptured spleen NOS, splenic rupture (diagnosis), splenic rupture, Rupture spleen, Spleen rupture of, Splenic Rupture [Disease/Finding], spleen fragmentation, rupture splenic, rupture spleen, spleen ruptured, Rupture;spleen, rupture of spleen, spleen rupture, ruptured spleen, ruptures spleen, Ruptured spleen NOS (disorder), Splenic rupture, Disruption of spleen, Fragmentation of spleen, Pulped spleen, Rupture of spleen, Rupture of spleen (disorder), rupture; spleen, spleen; rupture, rupture of the spleen
Dutch ruptuur milt, ruptuur van milt, milt; ruptuur, ruptuur; milt, miltruptuur, Miltruptuur, Ruptuur, milt-
German Riss Milz, Riss der Milz, Milzriss, Milzruptur
Japanese 脾臓破裂, 脾破裂, ヒゾウハレツ, ヒハレツ
Swedish Mjältbristning
Czech slezina - ruptura, Ruptura sleziny
Finnish Pernan repeämä
Russian SELEZENKI RAZRYV, СЕЛЕЗЕНКИ РАЗРЫВ
Spanish disrrupción de bazo, Rotura del bazo, Rotura esplénica, ruptura esplénica, SAI, ruptura esplénica, SAI (trastorno), fragmentación de bazo, ruptura de bazo (trastorno), ruptura de bazo, Rotura del Bazo
Croatian SLEZENA, RUPTURA
Polish Pęknięcie śledziony
Hungarian Lépruptura
Norwegian Miltruptur, Sprukken milt, Brist i milten
Portuguese Ruptura do Baço, Ruptura do baço, Ruptura Esplênica
French Rupture de la rate, Rupture de rate, Rupture splénique
Italian Rottura della milza

Ontology: Injury of spleen (C0160405)

Concepts Injury or Poisoning (T037)
ICD9 865
ICD10 S36.0 , S36.00
SnomedCT 210196007, 157342001, 269157005, 23589004
English Injury to spleen, Injury to spleen NOS, injury of spleen, injury of spleen (diagnosis), Splenic injury, Unspecified injury of spleen, Injury of spleen, unspecified, injury splenic, injury to spleen, Injury;spleen, injury spleen, injuries splenic, splenic injury, injuries spleen, spleen injury, Injury to spleen NOS (disorder), Injury of spleen, Injury of spleen (disorder), injury; spleen, spleen; injury, Injury of spleen, NOS
Italian Traumatismo della milza
German Verletzung der Milz, Milzverletzung
Japanese 脾臓損傷, ヒゾウソンショウ
Czech Poranění sleziny
Korean 지라의 손상
Hungarian Lépsérülés
Spanish lesión esplénica, SAI, lesión de bazo, SAI (trastorno), lesión de bazo, SAI, injuria del bazo, lesión traumática del bazo (trastorno), lesión traumática del bazo, traumatismo esplénico, Lesión traumática del bazo
Dutch letsel; milt, milt; letsel, Letsel van milt, miltletsel
Portuguese Lesão traumática do baço
French Lésion de la rate