Splenic trauma
Key points
Spleen Injury Scale (2018 Revision) American Association of Surgery of Trauma (AAST)
Grade I (Abbreviated injury scale (AIS) Severity 2):
Subcapsular haematoma <10% of surface area
Parenchymal laceration <1 cm depth
Capsular tear
Grade II (AIS Severity 2):
Subcapsular haematoma 10-50% of surface area
Intraparenchymal haematoma <5 cm
Parenchymal laceration 1-3 cm depth
Grade III (AIS Severity 3):
Subcapsular haematoma >50% of surface area
Ruptured subcapsular or intraparenchymal haematoma ≥5 cm
Parenchymal laceration >3 cm depth
Grade IV (AIS Severity 4):
Any injury with splenic vascular injury or active bleeding confined within the splenic capsule
Parenchymal laceration involving segmental or hilar vessels causing >25% devascularisation
Grade V (AIS Severity 5):
Any injury with splenic vascular injury and active bleeding extending beyond the spleen into the peritoneum
Hilar vascular injury that devascularises the spleen
Shattered spleen
Management
Isolated splenic injury can be managed non-operatively in almost all cases
Do not accept patients with grade 3 injury or above for transfer without a PICU bed available
Set a transfusion threshold as to when the patient will be taken to theatre
Embolisation is reserved for stable patients only
Management of splenic injuries if the patient is having a trauma laparotomy for other reasons:
Grade 1-3, stable, with no head or other serious injury - Splenorraphy
Grade 4 and 5 - Splenectomy
Splenectomy
Divide short gastrics
Divide splenocolic ligament
Mobilise pancreatic tail
In emergency, can drag spleen into midline, dividing lateral attachments bluntly, and clamp the hilum
Complications
Pleural effusion
Abscess
Overwhelming post-splenectomy infection (OPSI)
Pancreatic fistula
Pancreatitis
Pseudoaneurysm - no need to re-image if asymptomatic - 89% thrombose
Pseudocysts - perform laparoscopic partial splenectomy
References
Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, Kaups K, Schuster K, Tominaga GT; AAST Patient Assessment Committee. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018 Dec;85(6):1119-1122. doi: 10.1097/TA.0000000000002058. Erratum in: J Trauma Acute Care Surg. 2019 Aug;87(2):512. doi: 10.1097/TA.0000000000002419. PMID: 30462622.
Choi, Pamela, et al. "Liver and Spleen Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829086/all/Liver and Spleen Trauma.
