Table 4 Statement summary

Diagnostic procedures

-The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient (GoR 1A).

-E-FAST is effective and rapid to detect free fluid (GoR 1A).

-CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients (GoR 1A).

-Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up (GoR 1B).

-Injury grade on CT scan, extent of free fluid, and the presence of PSA do not predict NOM failure or the need of OM (GoR 1B).

-The role of E-FAST in the diagnosis of pediatric spleen injury is still unclear (GoR 1A).

-A positive E-FAST examination in children should be followed by an urgent CT in stable patients (GoR 1B).

-Complete abdominal US may avoid the use of CT in stable patients (GoR 1B).

-Contrast-enhanced CT scan is the gold standard in pediatric splenic trauma (GoR 1A).

-Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization (GoR 1B).

-CT scan is suggested in children at risk for head and thoracic injuries, need for surgery, recurrent bleeding, and if other abdominal injuries are suspected (GoR 1A).

-Injury grade on CT scan, free fluid amount, contrast blush, and the presence of pseudo-aneurysm do not predict NOM failure or the need for OM (GoR 1B).

Non-operative management

• General indications

-NOM is recommended as first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma (GoR 2A).

-Patients with moderate-severe blunt and all penetrating splenic injuries should be considered for transfer to dedicated pediatric trauma centers after hemodynamic stabilization (GoR2A).

-NOM of spleen injuries in children should be considered only in an environment that provides capability for patient continuous monitoring, angiography, and trained surgeons, an immediately available OR and immediate access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred (GoR 2A).

-NOM should be attempted even in the setting of concomitant head trauma; unless the patient is unstable, this might be due to intra-abdominal bleeding (GoR 2B).

• Blunt/penetrating trauma

-Patients with hemodynamic stability and absence of other abdominal organ injuries requiring surgery should undergo an initial attempt of NOM irrespective of injury grade (GoR 2A).

-NOM of moderate or severe spleen injuries should be considered only in an environment that provides capability for patient intensive monitoring, AG/AE, an immediately available OR and immediate access to blood and blood product or alternatively in the presence of a rapid centralization system and only in patients with stable or stabilized hemodynamic and absence of other internal injuries requiring surgery (GoR 2A).

-NOM in splenic injuries is contraindicated in the setting of unresponsive hemodynamic instability or other indicates for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement) (GoR 1A).

-In patients being considered for NOM, CT scan with intravenous contrast should be performed to define the anatomic spleen injury and identify associated injuries (GoR 2A).

-AG/AE may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective from injury grade (GoR 2B).

-Strong evidence exists that age above 55 years old, high ISS, and moderate to severe splenic injuries are prognostic factors for NOM failure. These patients require more intensive monitoring and higher index of suspicion (GoR 2B).

-Age above 55 years old alone, large hemoperitoneum alone, hypotension before resuscitation, GCS < 12 and low-hematocrit level at the admission, associated abdominal injuries, blush at CT scan, anticoagulation drugs, HIV disease, drug addiction, cirrhosis, and need for blood transfusions should be taken into account, but they are not absolute contraindications for NOM (GoR 2B).

-In WSES class II–III spleen injuries with associated severe traumatic brain injury, NOM could be considered only if rescue therapy (OR and/or AG/AE) is rapidly available; otherwise, splenectomy should be performed (GoR 1C).

Blunt trauma

-Blunt splenic injuries with hemodynamic stability and absence of other internal injuries requiring surgery, should undergo an initial attempt of NOM irrespective of injury grade (GoR 2A).

-In hemodynamically stable children with isolated splenic injury splenectomy should be avoided (GoR 1A).

-NOM is contraindicated in presence of peritonitis, bowel evisceration, impalement or other indications to laparotomy (GoR 2A).

-The presence of contrast blush at CT scan is not an absolute indication for splenectomy or AG/AE in children (GoR 2B).

Intensive care unit admission in isolated splenic injury may be required only for moderate and severe lesions (GoR 2B).

Penetrating trauma

-No sufficient data validating NOM for penetrating spleen injury in children exist.

The role of angiography/angioembolization (AG/AE)

-AG/AE may be performed in hemodynamically stable and rapid responder patients with moderate and severe lesions and in those with vascular injuries at CT scan (contrast blush, pseudo-aneurysms and arterio-venous fistula) (GoR 2A).

-In patients with bleeding vascular injuries and in those with intraperitoneal blush, AG/AE should be performed as part of NOM only in centers where AG/AE is rapidly available. In other centers and in case of rapid hemodynamic deterioration, OM should be considered (GoR 2B).

-In case of absence of blush during angiography, if blush was previously seen at CT scan, proximal angioembolization could be considered (GoR 2C).

–AG/AE should be considered in all hemodynamically stable patients with WSES grade III lesions, regardless with the presence of CT blush (GoR 1B).

–AG/AE could be considered in patients undergone to NOM, hemodynamically stable with sings of persistent hemorrhage regardless with the presence of CT blush once excluded extra-splenic source of bleeding (GoR 1C).

–Hemodynamically stable patients with WSES grade II lesions without blush should not underwent routine AG/AE but may be considered for prophylactic proximal embolization in presence of risk factors for NOM failure (GoR 2B).

–In the presence of a single vascular abnormality (contrast blush, pseudo-aneurysms, and artero-venous fistula) in minor and moderate injuries, the currently available literature is inconclusive regarding whether proximal or distal embolization should be used. In the presence of multiple splenic vascular abnormalities or in the presence of a severe lesion, proximal or combined AG/AE should be used, after confirming the presence of a permissive pancreatic vascular anatomy (GoR 1C).

–In performing, AG/AE coils should be preferred to temporary agents (GoR 1C).

-The vast majority of pediatric patients do not require AG/AE for CT blush or moderate to severe injuries (GoR 1C).

-AG/AE may be considered in patients undergone to NOM, hemodynamically stable with sings of persistent hemorrhage not amenable of NOM, regardless with the presence of CT blush once excluded extra-splenic source of bleeding (GoR 1C).

-AG/AE may be considered for the treatment of post-traumatic splenic pseudo-aneurysms prior to patient discharge (GoR 2C).

-Patients with more than 15 years old should be managed according to adults AG/AE-protocols (GoR 1C).

Operative management (OM)

-OM should be performed in patients with hemodynamic instability and/or with associated lesions like peritonitis or bowel evisceration or impalement requiring surgical exploration (GoR 2A).

-OM should be performed in moderate and severe lesions even in stable patients in centers where intensive monitoring cannot be performed and/or when AG/AE is not rapidly available (GoR 2A).

-Splenectomy should be performed when NOM with AG/AE failed, and patient remains hemodynamically unstable or shows a significant drop in hematocrit levels or continuous transfusion are required (GoR 2A).

–During OM, salvage of at least a part of the spleen is debated and could not be suggested (GoR 2B).

–Laparoscopic splenectomy in early trauma scenario in bleeding patients could not be recommended (GoR 2A).

-Patients should undergo to OM in case of hemodynamic instability, failure of conservative treatments, severe coexisting injuries necessitating intervention and peritonitis, bowel evisceration, impalement (GoR 2A).

-Splenic preservation (at least partial) should be attempted whenever possible (GoR 2B).

Short- and long-term follow-up

–Clinical and laboratory observation associated to bed rest in moderate and severe lesions is the cornerstone in the first 48–72 h follow-up (GoR 1C).

–CT scan repetition during the admission should be considered in patients with moderate and severe lesions or in decreasing hematocrit, in presence of vascular anomalies or underlying splenic pathology or coagulopathy, and in neurologically impaired patients (GoR 2A).

–In the presence of underlying splenic pathology or coagulopathy and in neurologically impaired patients CT follow-up is to be considered after the discharge (GoR 2B).

–Activity restriction may be suggested for 4–6 weeks in minor injuries and up to 2–4 months in moderate and severe injuries (GoR 2C).

–In hemodynamic stable children without drop in hemoglobin levels for 24 h, bed rest should be suggested (GoR 2B).

–The risk of pseudo-aneurysm after splenic trauma is low, and in most of cases, it resolves spontaneously (GoR 2B).

–Angioembolization should be taken into consideration when a pesudoaneurysm is found (GoR 2B).

–US (DUS, CEUS) follow-up seems reasonable to minimize the risk of life-threatening hemorrhage and associated complications in children (GoR 1B).

–After NOM in moderate and severe injuries, the reprise of normal activity could be considered safe after at least 6 weeks (GoR 2B).

Thrombo-prophylaxis

–Mechanical prophylaxis is safe and should be considered in all patients without absolute contraindication to its use (GoR 2A).

– Spleen trauma without ongoing bleeding is not an absolute contraindication to LMWH-based prophylactic anticoagulation (GoR 2A)

–LMWH-based prophylactic anticoagulation should be started as soon as possible from trauma and may be safe in selected patients with blunt splenic injury undergone to NOM (GoR 2B).

–In patient with oral anticoagulants the risk-benefit balance of reversal should be individualized (GoR 1C).

Infections prophylaxis in asplenic and hyposplenic adult and pediatric patients