Western Trauma Association (WTA) Critical Decisions in
Trauma: Management of Adult Blunt Splenic Trauma
Frederick A. Moore, MD, James W. Davis, MD, Ernest E. Moore, Jr., MD, Christine S. Cocanour, MD,
Michael A. West, MD, and Robert C. McIntyre, Jr., MD
J Trauma. 2008;65:1007–1011.
based on the expert opinion of WTA members and published
observational studies. We recognize that variability in deci-
sion making will continue. We hope this management algo-
rithm will encourage institutions to develop local protocols
based on the resources that are available and local expert
consensus opinion to apply the safest, most reliable manage-
ment strategies for their patients. What works at one institu-
tion may not work at another. The algorithm contains letters
A through K, which corresponds to lettered text. This text is
intentionally concise and its purpose is to navigate the reader
through the algorithm and to identify and discuss the gray
zones in the logic of this decision making. This annotated
algorithm is intended to (a) serve as a quick reference for
bedside clinicians, (b) foster more detailed patient care pro-
tocols that will allow for prospective collection of data to
identify best practices, and (c) generate research projects to
answer specific questions concerning decision making in the
management of adult blunt splenic trauma.
his is a position article from members of the Western
Trauma Association (WTA). Because there are no pro-
spective randomized trials, the algorithm (Fig. 1) is
Management of blunt splenic trauma has changed dras-
tically during the past 30 years. In the mid-1970s, recognition
of the spleen’s immunologic importance and the lifelong risk
of overwhelming postsplenectomy sepsis provided the ra-
tionale for avoiding splenectomy. Although the adult sur-
geons were focused on perfecting operative splenic salvage
techniques,1–3the pediatric surgeons provided convincing
evidence that the best way to salvage the spleen was not to
operate.4–6Adult trauma surgeons were slow to adopt non-
operative management (NOM) because early reports of its
use in adults documented a 30% to 70% failure rate of which
two-thirds underwent total splenectomy.7–10There was also a
concern about missing serious concomitant intra-abdominal
injuries.11–13However, with increasing experience with NOM,
recognition that negative laparotomies caused significant
morbidity and the availability of higher quality computerized
tomographic (CT) scanning, NOM became the standard of
care for adults by the mid-1990s.14–19Over the next decade,
the percentage of patients in which NOM was pursued in-
creased from 30% to 60% to as high as 85% as previous
expert opinion contra-indications (e.g. advanced age, fear of
missing a hollow viscus injury (HVI), ?2 units of packed
red blood cell transfusion, neurologic impairment, and
high grades injuries) were refuted.20–26Additionally, angio-
embolization (AE) was increasingly used as a NOM adjunct,
and the reported failure rate of 12% to 13% dropped to as low
as 2%.27–36It is unclear whether this decrease in the failure
rate is due to the success of AE or more liberal definitions of
failure. Table 1 lists the most recent updated series of adult
splenic trauma from US trauma centers (series with ?150
cases published since 2000). Variability in management strat-
egies still exist. Important factors that drive management
decisions in these trauma centers include (a) presence and
severity of hemodynamic instability, (b) results of the initial
workup of blunt abdominal trauma, which includes some
combination of the focused abdominal sonography for trauma
(FAST) examination, abdominal CT scan, and diagnostic
peritoneal aspirate or diagnostic peritoneal lavage, (c) avail-
ability and indications for angiography, (d) definition of fail-
ure, and (e) use of follow-up abdominal CT scanning.
Annotated Text For Figure 1
A. The initial assessment of patients with suspected blunt
abdominal trauma should focus on the abdominal exam-
ination (tenderness and abdominal wall eccymosis), vital
signs, and response to resuscitation. In patients with ev-
idence of shock or overt serious injury, blood should be
Submitted for publication April 17, 2008.
Accepted for publication August 14, 2008.
Copyright © 2008 by Lippincott Williams & Wilkins
From the Weill Cornell Medical College (F.A.M.), New York, New
York; University of California, San Francisco (J.W.D.), San Francisco,
California; University of Colorado Health Science Center (E.E.M., R.C.M.),
Denver, Colorado; University of California Davis Medical Center (C.S.C.),
Sacramento, California; and Northwestern University (M.A.W.), Chicago,
Presented at the 38th Annual Meeting of the Western Trauma Association
February 24–March 1, 2008, Squaw Creek, Olympic Valley, California.
Address for reprints: Frederick A. Moore, MD, Department of
Surgery, 6550 Fannin Street, SM1661A, Houston, TX 77030; email:
The Journal of TRAUMA?Injury, Infection, and Critical Care
Volume 65 • Number 5
immediately drawn for laboratory testing including com-
plete blood count, electrolytes, markers of metabolic
stress (base deficit or lactate), coagulation profile, and
blood typing. Adequate intravenous (IV) access should be
obtained for resuscitation and potential IV contrast
administration. There is considerable variability in the
definition of hemodynamic instability and there is no
validated scoring system. Table 2 depicts a modified
hemodynamic instability score.36Systolic blood pressure
?90 mm Hg to define significant hypotension and heart
rate ?130 beat per minute to define serious tachycardia
was taken from the recently published guidelines for
shock resuscitation developed by the National Institutes
of Health sponsored Glue Grant consortium.37Baseline
systolic blood pressure and heart rate, how they response
to initial advanced trauma life support recommended vol-
ume loading and the need for ongoing for resuscitation
are used to grade hemodynamic instability. We propose
that this score be used for early triage decision making
and be validated in prospective studies. Stable patients
(grade 0–2) should be triaged to the CT scanner.
B. Unstable patients (grade 3–5) should have a FAST exam-
ination done (if available and reliable) after the initial
ABCs. Patients who stabilize with initial volume loading
and require modest ongoing resuscitation (grade 3) may
be triaged to the CT scanner if readily available. Grade 3
patients who are FAST (?) are presumed to have a
hemoperitoneum. This information should prompt closer
Fig. 1. Adult blunt splenic trauma.
Table 1 Updated United States Adult Splenic Trauma Case Series Since 2000
Total NOM, n (%)Angio (%) Failure (%)Mortality (%)
UT Houston 200021
UT Knoxville 200135
UT San Antonio 200429
University of Michigan 200430
University of Maryland 200531
Case Western 200532
UT Memphis 200733
University of Pittsburgh 200734
* One death attributed to nonoperative management (NOM).
NR, not reported.
Table 2 Hemodynamic Instability Score38
Grade 0: No significant hypotension (systolic blood pressure ?SBP?
?90 mm Hg) or serious tachycardia (heart rate ?HR? ?130)
Grade 1: Hypotension or tachycardia by report but none recorded
in emergency department (ED)
Grade 2: Hypotension or tachycardia responsive to initial volume
loading with no ongoing fluid or PRBC requirement
Grade 3: Hypotension or tachycardia responsive to initial volume
loading with modest ongoing fluid (?250 mL/h) or PRBC
Grade 4: Hypotension or tachycardia only responsive to ?2 L of
volume loading and the need for vigorous ongoing fluid infusion
(?250 mL/h) and PRBC transfusion
Grade 5: Hypotension unresponsive to fluid and PRBC transfusion
The Journal of TRAUMA?Injury, Infection, and Critical Care
monitoring and quicker processing through the CT scan-
ner. On the other hand, FAST (?) patients who require
vigorous ongoing resuscitation (grade 4 and 5 instability)
should be triaged to the operating room (OR). In some
cases patients with grade 4 instability might be triaged to
the CT scanner with caution. This would be a reasonable
option if the CT scanner is readily available and (a) a
plausible explanation for instability exists (e.g., tension
pneumothorax, pelvic fracture, neurogenic shock), or (b)
the CT scan results will change triage decision making
(e.g., epidural hematoma requiring craniotomy, torn tho-
racic aorta requiring thoracotomy, massive brain injury to
declare futility, or vascular blush associated with a pelvic
fracture prompting AE).
C. A negative FAST does not reliably exclude intraperito-
neal hemorrhage and should be repeated again as part of
the secondary survey. Grade 5 instability with a negative
FAST examination is an uncomfortable scenario. It is not
prudent to triage this patient to the CT scanner, rather this
patient should stay in the trauma resuscitation room and
differential diagnosis of refractory shock should be pur-
sued. If a missed source of hemorrhage is still a concern,
despite a second negative FAST in an unstable patient,
a diagnostic peritoneal aspirate should be considered.
A viable alternative is to go directly to the OR in patients at
risk of imminent cardiac arrest for exploratory laparotomy.
D. Other causes of persistent instability include exsanguinat-
ing hemorrhage from a severe pelvic fracture and massive
hemothorax, whereas causes of nonhemorrhagic shock
include tension pneumothorax, cardiac tamponade,
myocardial contusion or infarction, air embolism, and
E. Abdominal CT scanning is the gold standard diagnostic
test if NOM is to be pursued. Appropriate timing of IV
contrast is crucial to define the extent of splenic injury and
identify vascular blushes. Controversy exists over the
need for oral contrast to diagnose HVI and its potential for
causing severe aspiration pneumonitis.38
F. Although the grade of splenic injury (Table 3) does cor-
relate with success of NOM, it is not accurate enough to
predict failure or success in individual patients.39,40There
is a selection bias in who gets a CT scan. Patients with
high grade injuries who are bleeding profusely are triaged
early to the OR based on grade of instability and the
results of the FAST examination. Additionally, in blunt
trauma the spleen tends to fracture along the relatively
avascular plains between the segmental polar arteries. As
a result, the severity of the injury seems severe because
there is a deep laceration into the parenchyma but there is
only limited bleeding.
G. As CT scanning technology has improved, more blushes
are being seen and these may be helpful in predicting
failure of NOM. A modified Splenic Injury Scale that
incorporates vascular blush information into the anatomic
descriptions used in the American Association for the
Surgery of Trauma scoring system has been developed
but needs validation.41
At this point in time, if vascular blush is seen on the
initial CT scan and the patient is hemodynamically stable,
screening angiography may be used as an adjunct to NOM
based on local consensus. In patients with grade 3–4 hemo-
dynamic instability, triage to the OR is prudent unless inter-
vention radiology is immediately available. Patients with
grade 5 instability should be taken directly to the OR. If a
blush is seen on a delayed follow-up CT scan, screening
angiography is recommended in the hemodynamically stable
patient. There is considerable variability in the use of angiog-
raphy across centers (Table 1). Although more aggressive use
of angiography is associated with the highest rates of NOM
(?80%) and the lowest rates of failure (2–5%), there is
ongoing debate over the optimal use of this intervention
because it is labor intensive and there have been several reports
that document a surprisingly high rate of complications.27,28In
our WTA multi-institutional experience, we reported on 140
patients who underwent AE, of which 27 (20%) suffered
major complications including 16 (11%) failure to control
bleeding (requiring 9 splenectomies and 7 repeat AE), 4 (3%)
missed injuries, 6 (4%) splenic abscesses, and 1 iatrogenic
H. Arteriograghy requires transport to the interventional ra-
diologist suite, where the patient should be monitored to
the same standards as an intensive care unit. Therapeutic
embolization is done if an aneurysm, arteriovenous fis-
tula, or extravasation is found on the screening angio-
gram. There is some controversy over the optimal method
of AE (i.e., main splenic artery embolization vs. distal
selective artery embolization vs. combination). Main
splenic artery embolization reduces bleeding by reducing
perfusion pressure, but this may not prevent late
Table 3 American Association for the Surgery of
Trauma Splenic Injury Scale (1994 Revision)42
I Hematoma subcapsular, ?10% surface area
Laceration capsular, ?1 cm parenchymal depth
Hematoma subcapsular, 10–50% surface area, ?5 cm
Laceration, 1–3 cm depth which does not involve
Hematoma subcapsular, ?50% surface area or
Ruptured subcapsular or parenchymal hematoma
Intrapaenchymal hematoma ?5 cm or expanding
Laceration ?3 cm depth or involving trabecular vessel
Laceration involving segmental or hilar vessels producing
Devascularization (?25% of spleen)
Laceration, completely shattered spleen
Vascular, hilar vascular injury which devascularizes
* Advance one grade for multiple injuries, up to grade 3.
Management of Adult Blunt Splenic Trauma
Volume 65 • Number 5
pseudoanuerysm rupture and will likely not treat an arte-
riovenous fistula.42On the other hand, distal selective
embolization can effectively stop blood flow in polar
arteries but can result in tissue infarction with local ab-
scess formation. Local expert consensus should standard-
ize these practices and prospectively characterize patient
outcomes to define the best technique.
I. When pursuing NOM of splenic injuries it is important to
exclude other injuries that require operative intervention.
Historically, the risk of missing a HVI received the most
attention. In the eight recent series depicted in Table 1,
where the average frequency of NOM was 70%, there was
only one case of a missed HVI in the 2,355 patients
selected for NOM. This was a missed colon injury and
accounted for the only death in these series attributable to
J. When failure due to bleeding is dichotomized as before or
after 48 hours (early vs. late), there is a low but disturbing
incidence of late bleeds (2–4%) presumably due to de-
layed rupture of splenic artery pseudoanuerysms.26,43,44
These late bleeds tend to occur at 4 days to 8 days, but
some occur weeks later. The practice of obtaining fol-
low-up CT scans is also quite variable. The University of
Tennessee Memphis group has championed the concept
of obtaining CT scans before early hospital discharge of
patients with high grade splenic injuries. However, their
most recent series demonstrates that roughly a quarter of
pseudoanuerysms occurred in grade 1 and 2 injuries and
over half occurred in grade 3 injuries. This is another
issue that requires prospective study before definitive
recommendations can be made. In general, follow-up CT
scans as out patients are not helpful but may be used
selectively to confirm healing in patients who are asking
to be released to pursue high risk behavior (such a bull
riding or football).
K. The decision of whether to perform a splenectomy is
dependent on the patient’s condition and associated
injuries. Unfortunately, most patients go to the OR
because of hemodynamically instability and splenec-
tomy is the most prudent option. Splenic salvage
should be pursued in the hemodynamically stable pa-
tient. Techniques include topical hemostatic agents, argon
beam coagulation, direct suture repair, partial resection,
wrapping the spleen with absorbable mesh, and splenic
reimplantation. Pledgets are generally used when suturing
splenic lacerations and margins of segmental resections. It
is important to confirm hemostasis before closure of the
midline fascia. Packing of the spleen in damage control
surgery should be discouraged because splenectomy is
fairly simple and definitive. Splenic reimplantation in a
patient without significant bacterial contamination is a
safe but unproven method of preserving splenic function
to protect against overwhelming postsplenectomy
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Management of Adult Blunt Splenic Trauma
Volume 65 • Number 5