Splenic Trauma Grading & Management

[Aaron Fritts MD]
Well, let's jump into the meat of splenic trauma, the topic for today. How do these patients typically present in your practice?

[Chris Grilli MD]
Like I mentioned, we are a level one trauma center, so this is something we do plenty of. We have a lot of interactions with the trauma team every day, spleen or otherwise. As we know, most of these are blunt-force traumas. Occasionally, we'll get a penetrating trauma splenic injury that does go to IR. It's definitely a very small minority of patients. Then when thinking about splenic injuries, you could have an acute injury. The patient comes in, they're stable or they're unstable, and they get triaged right away.

Then there's also when it comes to spleens, delayed splenic rupture which we could touch on later, where the spleen's fine initially. Then all of a sudden, you're dealing with a bit of an acute situation for hours, days, or sometimes even longer down the road. We see both of those really at Christiana. Splenic Embol has been going on for a long time, since the seventies when they were using autologous blood clots. This is nothing new. But really, it took a couple of decades for IR to really get involved in the trauma algorithm. In the ‘90s they were already identifying defects in their algorithm.

They were just starting to use more commonly cross-sectional imaging as opposed to just ultrasound or just lavage. Really, we're seeing that if they see blush on CT scans, their fail rate for OBS alone was near 70%. That brings the question of, what do you do with these patients like this? Do you jump all the way to taking their spleens out or are there other options? That's where IR has started to get involved and now is well established as part of their algorithm. For example, at my institution, when the trauma surgeon calls me, it's usually well-siphoned out already. They're not sending me grade ones or on the other spectrum, very unstable patients to evaluate.

They're usually appropriate. We're talking about three, four, five splenic laceration grades using the AAST guidelines. Usually, although not all the time, those are stable patients. Maybe we should go into this because we do have some medical students probably listening.

[Aaron Fritts MD]
Yes. Let's talk about the grades of splenic injury and the treatments for each.

[Chris Grilli MD]
Knowing these will help dictate the rest of this conversation. If we're using the AAST guidelines, we were talking about five spleen grades, obviously from zero to five, getting worse all the way from grade one, which is just a very small spleen laceration. We've seen these on CTs before. You could barely see the dark laceration. On the scan, it's less than a centimeter. They might have a small hematoma, but it's less than 10% or something small. Then grade two, there’s a little bit more of that but still really nothing large in the parenchymal intraparenchymal really to worry about.

Then you get up to three where now you have either a ruptured subcapsular or a parenchymal hematoma. You have a much deeper spleen laceration - 3 centimeters. Then grades four and five, we're starting to talk about the devascularization of the spleen itself. In grade four, more than 25% of the spleen is devascularized. In grade five, there is a completely shattered spleen, which is completely devascularized. So obviously, it is a higher grade. The initial guidelines didn't even mention hematomas or devascularization, but in 2018, AAST started to notice. If we see involvement of the vasculature, or if we see large hematoma, these patients are doing much worse.

So in 2018, they modified it and added the hematoma sizes. They added the stuff about the devascularized portions of the spleen so as to better triage their patients. Even in the world, there's a world organization of emergency surgery that also has a grading system, which I like even more. It's simpler, which I always prefer. It's only four grading classes. It lumps the lower-grade AAST together into a one. Then as it gets higher, obviously more vascular involvement, but their grade four is just anybody who's unstable which makes sense.

You could have a 1-centimeter laceration, but if the patient's unstable or not doing well, then that's not going to be the same as a patient who has a 1-centimeter laceration and is rock solid. Their grading system brings in more of the clinical side of things a little bit, which I really do like.