Table 3.

WSES Spleen Trauma Classification for adult and pediatric patients

	WSES class	Mechanism of injury	AAST	Hemodynamic statusa, b	CT scan	First-line treatment in adults	First-line treatment in pediatric
Minor	WSES I	Blunt/penetrating	I–II	Stable	Yes + local exploration in SWd	NOMc + serial clinical/laboratory/radiological evaluation Consider angiography/angioembolization	NOMc + serial clinical/laboratory/radiological evaluation Consider angiography/angioembolization
Moderate	WSES II	Blunt/penetrating	III	Stable
	WSES III	Blunt/penetrating	IV–V	Stable		NOMc All angiography/angioembolization + serial clinical/laboratory/radiological evaluation
Severe	WSES IV	Blunt/penetrating	I–V	Unstable	No	OM	OM

SW stab wound, GSW gunshot wound

^a Hemodynamic instability in adults is considered the condition in which the patient has an admission systolic blood pressure < 90 mmHg with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs and/or admission base excess (BE) > − 5 mmol/l and/or shock index > 1 and/or transfusion requirement of at least 4–6 units of packed red blood cells within the first 24 h; moreover, transient responder patients (those showing an initial response to adequate fluid resuscitation, and then signs of ongoing loss and perfusion deficits) and more in general those responding to therapy but not amenable of sufficient stabilization to be undergone to interventional radiology treatments

^b Hemodynamic stability in pediatric patients is considered systolic blood pressure of 90 mmHg plus twice the child’s age in years (the lower limit is inferior to 70 mmHg plus twice the child’s age in years, or inferior to 50 mmHg in some studies). Stabilized or acceptable hemodynamic status is considered in children with a positive response to fluid resuscitation: 3 boluses of 20 mL/kg of crystalloid replacement should be administered before blood replacement; positive response can be indicated by the heart rate reduction, the sensorium clearing, the return of peripheral pulses and normal skin color, an increase in blood pressure and urinary output, and an increase in warmth of extremity. Clinical judgment is fundamental in evaluating children

^cNOM should only be attempted in centers capable of a precise diagnosis of the severity of spleen injuries and capable of intensive management (close clinical observation and hemodynamic monitoring in a high dependency/intensive care environment, including serial clinical examination and laboratory assay, with immediate access to diagnostics, interventional radiology, and surgery and immediately available access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred

^dWound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels