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  • Dr Eanna Mac Suibhne

SPLENIC TRAUMA

Updated: Nov 3, 2023



Dr Eanna Mac Suibhn Emergency Registrar

Peer review: Dr Hector Thomson

Editor: 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 th