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Splenic Trauma Grading & Management

Author Sai Govindu covers Splenic Trauma Grading & Management on BackTable VI

Sai Govindu • Jun 16, 2023 • 373 hits

Splenic trauma grading under the American Association for the Surgery of Trauma (AAST) guidelines play a crucial role in determining the therapeutic approach. Splenic injuries, often resulting from blunt-force trauma, encompass a spectrum of acute to delayed rupture scenarios, calling for dynamic and precise medical responses. Spleen injuries are generally categorized under the AAST guidelines into five grades, ranging from minor spleen lacerations to complete devascularization. Interventional radiologists Dr. Chris Grilli and Dr. Aaron Fritts discuss how modern splenic trauma management algorithm significantly benefits from interventional radiology (IR), a welcome alternative to traditional spleen removal. The balance between IR and surgical interventions is subject to the patient's stability and the severity of the injury, guided by the important findings of studies such as those conducted by UMass. This reality is especially pronounced in pediatric cases, where stability largely influences the choice between observation, embolization, or surgery. Regardless of demographic, the increasing trend towards embolization in stable patients with high-grade injuries is reshaping the landscape of splenic trauma treatment.

This article features excerpts from the BackTable Vascular & Interventional Podcast. We've provided the highlights here, and you can listen to the full episode below.

The BackTable Brief

• Splenic trauma primarily results from blunt-force injuries and can present as either acute or delayed rupture.

• Splenic injuries are graded under AAST guidelines into five grades, ranging from minor spleen lacerations to complete devascularization. The 2018 modification of AAST guidelines includes details about hematoma sizes and devascularized portions of the spleen to improve patient triage.

• An alternative grading system by the World Organization of Emergency Surgery considers patient stability, integrating a more clinical perspective into the splenic trauma grading process.

• Patient stability is a critical factor in deciding whether splenic trauma is managed in the OR or IR suite. Unstable patients are generally directed to the OR while stable patients are considered for IR.

• Pediatric splenic trauma management leans towards observation for stable patients, regardless of spleen injury grade. Unstable pediatric patients are more likely to require surgery, limiting the role of IR in this demographic.

Splenic Trauma Grading & Management: Embolization vs Surgery

Table of Contents

(1) Splenic Trauma Grading and Management

(2) Splenic Trauma Management: Embolization vs Surgery

Splenic Trauma Grading and Management

Splenic injuries, typically arising from blunt-force traumas, can present in two primary forms: acute and delayed rupture. Acute cases involve patients who are either stable or unstable upon arrival, and they are triaged immediately. Delayed ruptures, however, can transform into acute situations hours, days, or even longer after the initial trauma when the spleen appears fine initially. Splenic trauma management of these injuries have evolved over the decades, particularly since the 1990s when the use of cross-sectional imaging became more common, revealing a high failure rate for observation (OBS) alone in the presence of a 'blush' on CT scans. The advent of interventional radiology (IR) has provided an alternative to spleen removal and is now an established part of the splenic trauma management algorithm. Generally, IR sees patients with three, four, and five spleen laceration grades under the American Association for the Surgery of Trauma (AAST) guidelines, although exceptions exist. It's essential to understand these grades as they help shape the trajectory of patient care.

[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.

Listen to the Full Podcast

Treatment Algorithms for Splenic Artery Embolizations with Dr. Chris Grilli on the BackTable VI Podcast)
Ep 270 Treatment Algorithms for Splenic Artery Embolizations with Dr. Chris Grilli
00:00 / 01:04

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Splenic Trauma Management: Embolization vs Surgery

Splenic trauma management is contingent upon the stability of the patient and varies between adults and pediatric patients. In its simplest form, unstable patients with splenic injuries should be sent to the operating room (OR), while stable patients are considered for Interventional Radiology (IR). However, this notion is not without exceptions, as a UMass study suggested that both stable and unstable patients could be managed in the IR suite without increasing complications or mortality. Pediatric patients offer a different approach altogether. Regardless of spleen injury grade, stable pediatric patients are typically observed, with embolization considered only when there is no clinical improvement. Unstable pediatric patients are more likely to be directed towards surgery, narrowing the role of IR in this demographic. The approach to splenic trauma management varies across institutions, but a clear trend points towards improved salvage rates with embolization over observation in high-grade injuries, particularly in adults.

[Aaron Fritts MD]
We got a few minutes left here to just briefly talk about aneurysms, which I would imagine you'd only really use coils. You can't really use plugs. Really coils would be the only thing you would use for aneurysms. How often are you guys treating those in your practice?

[Chris Grilli MD]
We get a few of those a year. For whatever reason in our practice, we get a lot more hypersplenism than we do aneurysms, but we do see a fair number of aneurysms. You're exactly right. We're using coils to do those - generally long packing coils. The longer the better, depending on the aneurysm size. We have also used covered stents in cases where we try to maintain flow to the spleen and just to try something different to be honest. We use a cover stent to cover it up, especially if there's a short neck and you feel like you can't seed a bunch of coils on the inside.

Also, another thing we've used is just coil, distal coil proximal, and don't coil the sack itself because as we've discussed already. Depending on where the aneurysm is, you're not going to kill the spleen by just coiling that small segment out. There's going to be robust collateral flow so you're good where you don't even have to pack the aneurysm sac. There are plenty of options when it comes to aneurysms and they can be a lot of fun to do. My favorite is just packing the sac though because it's fun to do and it's cool to do.

[Aaron Fritts MD]
What I've seen people do, is put a framing coil in there and then just pack it with fillers after that for the most part, but all detachables.

[Chris Grilli MD]
Detachables.

[Aaron Fritts MD]
Have you ever had an issue where a little end of a coil sticks out and you got to decide what to do? You try and snare it or just leave it as is because again, it's the spleen. It's not really going to shut down flow to the spleen. What do you do in those kinds of scenarios?


[Chris Grilli MD]
Oh, sure. That happens all the time. That's another thing you’d see with your GDAs and stuff like that where you just have a little tail sticking up. It's always on the last quail. You're always like, I think I'm done, but I'm going to put one more in and then that. It's always that one. When talking about the spleen, it's not a big deal. I would just leave it. Honest to God, even if a whole coil flicked off and fell into a segmental branch, you're not going to really worry about that. You're going to cause more damage, more radiation, more time, mucking around trying to get the thing out. Although it doesn't look pretty on your run or on your pictures, you have to put it all into perspective when deciding how to chase things like that.

[Aaron Fritts MD]
Splenic artery embolizations don’t always look pretty anyway. That’s trauma care.

[Chris Grilli MD]
Exactly. It looked like a mess no matter what.

[Aaron Fritts MD]
Exactly. I think that pretty much covers it. Anything else that we left behind, Chris, that would be useful to the audience when it comes to splenic artery embolization?

[Chris Grilli MD]
No, I don't think so. I mentioned they're going to be hospitalized for a couple of days. I do put these patients on PCAs often with or without a steroid bolster and then Toradol is also very useful to use. Sometimes I get this question often from the patient: do I need vaccinations? The data suggests you don't because you still do have remaining splenic parenchyma, which will eventually start to hypertrophy as well, which is sometimes why you need to do repeat procedures. You don't need to be vaccinated as long as you're leaving some spleen behind which is a common question. I think that covers it.

[Aaron Fritts MD]
Well, Chris, thank you so much for coming on. We really appreciate it. To our audience, if you have any questions or want to look up any of the resources that we mentioned, for example, the grading scale from 2018 AAST, we'll put those in the show notes so that you can have them ready and handy. Thanks, everybody for listening.

Podcast Contributors

Dr. Chris Grilli discusses Treatment Algorithms for Splenic Artery Embolizations on the BackTable 270 Podcast

Dr. Chris Grilli

Dr. Christopher Grilli is a practicing interventional radiologist with the ChristianCare Interventional Radiology Group in Delaware.

Dr. Aaron Fritts discusses Treatment Algorithms for Splenic Artery Embolizations on the BackTable 270 Podcast

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2022, December 9). Ep. 270 – Treatment Algorithms for Splenic Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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