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Table 1: AAST.
patient, who presents alterations in hemodynamic conditions,
Grade of Type of
Description with hypotension and tachycardia, it is always necessary to
injury injury
Subcapsular, not expanding, interesting less than 10% of hypothesize the possibility of an intra-abdominal injury,
Hematoma
the splenic surface area especially splenic, remembering that even fractures of
I
Capsule rupture, not bleeding, with a depth of no more than the long bones and pelvis can cause bleeding responsible
Laceration
1 cm for such hemodynamic instability, but the recognition of
Subcapsular, not expanding, interesting 10-50% of the
Hematoma fractures should not exclude an intra-abdominal cause, and
splenic surface, diameter less than 5 cm
II splenic injury is the most common. Since the classic J. West
Continuous capsule solution, active bleeding, with a depth
Laceration
of 1-3 cm, without the involvement of trabecular vessels et al. studies of preventable deaths that directly contributed
Subcapsular, involving more than 50% of the surface area to the development of trauma care systems in the United
or expanding; or ruptured subcapsular hematoma with States, mortality from missed or delayed diagnosis of splenic
Hematoma
III active bleeding; or intraparenchymal hematoma greater haemorrhages has remained at the top of the list of preventable
than 5 cm expanding
causes of death. The presence of multiple injuries should not
Laceration Depth greater than 3 cm or interesting trabecular vessels
distract the examiner from correctly recognizing the source
Hematoma Intraparenchymal hematoma rupture with active bleeding
and severity of the haemorrhage; in particular, hemodynamic
IV Laceration with segmental or hilar vessel involvement with
Laceration
major devascularization (more than 25%) changes cannot be attributed, until proven otherwise, to the
Hematoma Complete breakdown concurrent presence of neurologic injuries or substance abuse.
V
Laceration Hilar vessel injury with splenic devascularization Closed head trauma is associated in 30-40% of cases and
compromises or even eliminates the reliability of the patient’s
physical examination. Substance abuse has been documented
(Airway): patency and maintenance of the airway, protection
in 40% of patients involved in motorcycle accidents.
of the cervical spine; B (Breathing): adequate ventilation;
C (Circulation): adequate blood volume and cardiac output, Because of the unreliability of the objective examination
control of haemorrhage; D (Disability): neurological in these conditions, newer, more objective diagnostic means
assessment, establish the state of consciousness; E (Exposure): have been developed. Before activating complex diagnostic
expose the patient’s body to identify any injuries by preventing procedures, however, it is important to ensure good venous
hypothermia. Once these objectives have been achieved, the access routes and, above all, to set up good monitoring, to
mechanisms responsible for the trauma can be investigated in highlight the premonitory signs of an abrupt transition (typical
detail. in the early phase in the elderly and a relatively late phase in
the young) from a relative hemodynamic compensation to an
However, history and physical examination remain of
overt shock.
fundamental importance in the diagnosis of splenic trauma. In
particular, it will be necessary to investigate on:
Clinical examination [33,34]: The clinical examination
is followed by the instrumental one, standard radiological
a) The existence or not of hemodynamic instability (after
examination (Rx thorax, Rx pelvis, usually already performed
rapid volemic replenishment).
in the first phase of care) and an ultrasound FAST (Focused
b) The existence or not of signs suggestive of a visceral Assessment with Sonography in Trauma). Introduced during
perforation. the ‘90s, ultrasound has become an important diagnostic aid
in the evaluation of abdominal trauma. Its advantages include
c) The existence or not of signs of focus (pain, skin lesions, noninvasiveness, rapidity, and low cost. Compared with
seat belt marks). Diagnostic Peritoneal Lavage (DPL), for several years considered
a diagnostic gold standard, ultrasound provides similar but
On objective examination, signs of peritoneal irritation
more information. The presence of free intraperitoneal fluid
(pain, defensive contracture, rebound pain) may be evident;
in other situations, the hemoperitoneum may have a mild can be detected and quantified, unlike diagnostic peritoneal
irritating power on the peritoneum itself, allowing conspicuous lavage. These features make it the main diagnostic tool of
blood effusions with relatively poor objectivity. In particular, the first level in any abdominal trauma, ensuring particularly
for splenic trauma, there may be evidence of pain on percussion high reliability in the detection of a free abdominal effusion
or obvious ecchymosis and signs of soft tissue contusion over (sensitivity 91.4%, specificity 97.8%, accuracy 95.6%)
the left posterior costal hemiarchate, which are signs generally and sensitivity levels still satisfactory in the diagnosis of
present in splenic injury from direct trauma. Pain in the left liver injury (75%) or splenic (72%). The FAST protocol has
upper abdominal quadrant or that referred to the left shoulder evolved into E-FAST and subsequently into FAST ABCDE:
(Kehr’s sign) are often associated with splenic trauma. At least originally developed and codified to allow the recognition of
one-quarter of patients with fractures of the left last ribs also hemoperitoneum and hemopericardium, it has been extended
present with splenic trauma. However, these signs are unlikely to a large number of other targeted clinical applications,
to establish a direct correlation with splenic injury without always characterized by the rapidity of execution, with
further investigation. The onset of hemorrhagic shock at the important diagnostic and therapeutic benefits; with E-FAST
arrival of the patient in the “Shock Room” is not very frequent, (Extended FAST) the goal is also the ultrasound recognition
except in cases of complete or almost complete avulsion of the of pneumothorax. Recently, FAST ABCDE (Airways, Breathing,
spleen, or its plurifragmentation. Faced with a polytraumatized Circulation, Disability, Exposure), the latest evolution of the
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Citation: Perrotta G, Guerrieri E, Guerrieri M (2021) Splenic trauma: Definition, classifications, clinical profiles and best treatments. Open J Trauma 5(1): 019-036.
DOI: https://dx.doi.org/10.17352/ojt.000038