'PowerPoint presentation reviewing the literature regarding traumatic splenic injury. Intended for medical professionals and students interested in surgery. For educational purposes only.

1. Traumatic Splenic Injury
Dr. Joseph A. Di Como

3. Literature Review
● Splenic injury can be initially managed with observation, angiographic embolization, or surgery
depending upon the hemodynamic status of the patient, grade of splenic injury, and presence of
other injuries and medical comorbidities.
● Hemodynamically unstable – Based upon ATLS principles, the hemodynamically unstable
trauma patient with a positive FAST scan requires emergent abdominal exploration to determine
the source of intraperitoneal hemorrhage.
● Hemodynamically stable – Hemodynamically stable patients with low-grade (I to III) blunt or
penetrating splenic injuries without any evidence for other intra-abdominal injuries, active
contrast extravasation, or a blush on CT, may be initially observed safely. In general,
patients who meet the criteria for observation but who require intervention to manage extra-
abdominal injuries can also be safely observed.

4. Literature Review
• CT scan findings of contrast extravasation or vascular blush have higher
failure rates for observational management
• These patients may benefit from initial splenic embolization followed by
continued observation to verify the success of the intervention. Another
indication for embolization is intraparenchymal pseudoaneurysm formation.
• Splenic embolization is controversial for higher grade (IV, V) injuries and in
patients older than 55.
• Surgery is indicated in patients who cannot be adequately observed (due
to limited resources or other injuries), are unlikely to tolerate a significant
episode of hypotension, and those who fail nonsurgical management (ie,
observation, embolization).

5. Literature review
• Splenic trauma was nearly uniformly managed with surgical exploration
and splenectomy or attempted splenic salvage prior to the introduction of
nonoperative management algorithms in the pediatric population.
• What seemed initially to be a radical approach was adopted over time by
the adult trauma community. Nonoperative management, encompassing
both observation and embolization techniques, is used to manage 50 to 70
percent of cases, typically for patients with lower grade injuries.

6. Literature review
• The rationale for nonoperative management is based upon the assumption
that salvaging functional splenic tissue avoids the surgical and anesthetic
risks and complications associated with laparotomy and abrogates the risk
of early infectious complications, and postsplenectomy sepsis.
• Immune competence after injury that does not require removal of the
spleen (embolization) depends on the immunologic functionality of the
residual splenic tissue and does not appear to be grade specific. The small
risk of postsplenectomy sepsis appears higher at the extremes of age, but
may be influenced by concomitant immune deficiency from solid organ
transplantation, malignancy, and HIV disease.

7. Literature Review
• Nonoperative management is not appropriate in patients with hemodynamic instability,
generalized peritonitis, or for patients with other intra-abdominal injuries requiring surgical
exploration.
• Portal hypertension is a relative contraindication due to the increased venous pressures that
may prevent clot formation and control of hemorrhage even after successful splenic
embolization.
• In a review of the National Trauma Data Bank, patients with liver cirrhosis had higher rates of
complications, failure of nonoperative management, and mortality compared with noncirrhotic
patients.
• In a separate case control study, cirrhosis was an independent risk factor for splenectomy
following splenic injury. However, after propensity score matching, mortality after splenic injury
was associated only with the admission MELD score (Model for End-stage Liver Disease), and
not the splenectomy procedure.

8. Literature review
• Relative contraindications include higher-grade splenic injury (>Grade III), active contrast
extravasation, large volume hemoperitoneum, traumatic brain injury, refusal of blood transfusion
in the setting of pre-existing anemia, or altered neurologic status precluding adequate serial
abdominal examination.
• There is a higher failure rate of nonoperative management with increasing grade of injury,
though all grades of splenic trauma can bleed and often in an unpredictable fashion.
• The optimal management of hemodynamically stable patients with higher-grade (IV, V) injuries
remains controversial, though grade V injuries are generally unsuitable for embolization due to
vascular disruption. Some also consider Grade IV injuries to be a relative contraindication to
splenic embolization.

9. Literature Review
• Embolization is also relatively contraindicated in patients older than 55 due to higher failure rates
in these patients.
• The splenic capsule thins with age (age >55 years) and may render nonoperative management
of higher-grade injuries (>Grade III) in these patients less successful.
• However, injury severity-adjusted mortality rates do not appear significantly higher in this
population compared with younger patients. Retrospective reviews suggest, however, that
carefully selected individuals over 55 who are hemodynamically stable, and have no significant
medical comorbidities, can also be safely managed with observation, with or without
embolization.
• One examined 1008 patients ≥55 years of age who sustained blunt splenic injury . Of the
patients who did not require immediate surgical intervention, 75 percent were successfully
managed nonoperatively. Among three age groups, 55 to 64, 65 to 74, and >75 years of age,
failure rates for nonoperative management increased and were 19, 27, and 28 percent.

10. Literature Review
• Angiographic embolization was first applied to the management of splenic injury
in 1981.
• Success rates for embolization vary depending upon institution, embolization
technique, arterial accessibility, operator skill, and the type of embolization
material.
• Best when employed selectively in hemodynamically stable patients who have CT
findings that include active contrast extravasation and splenic pseudoaneurysm.

11. Literature Review
In a cohort analysis, 222 patients with blunt splenic injury treated between 1991 and 1998 were
compared with 408 patients treated between 1998 and 2005. The frequency of nonoperative
management (61 versus 85 percent, respectively), injury severity scale (21 versus 27,
respectively), frequency of splenic artery embolization (3 versus 23 percent, respectively) and
success of nonoperative management (77 versus 96 percent, respectively) all increased
significantly between the earlier and later cohort. Hospital mortality rates (12 versus 6 percent)
and mean hospital length (15 versus 9 days) decreased significantly.
●A retrospective, multicenter trial that included 1275 patients found that angioembolization
significantly increased the likelihood of splenic salvage (odds ratio [OR] 5, 95% CI 1.8-13.5).
●In a small study of 39 patients, splenic artery embolization increased the success rate for
nonsurgical management from 74 to 89 percent.