A 32-year-old man presents to the emergency department 2 hours after a motor vehicle collision with blunt abdominal trauma. He is haemodynamically stable with a heart rate of 92/min, BP 128/82 mmHg, and mild left upper quadrant tenderness. There is no peritoneal signs. Which investigation is most appropriate to assess for splenic injury?

Explanation

## Investigation of Choice for Splenic Injury in Stable Patient **Key Point:** In a haemodynamically stable patient with suspected splenic injury, contrast-enhanced CT (CECT) abdomen and pelvis is the gold standard investigation. It provides definitive diagnosis, grading of injury severity, and guides management decisions (conservative vs operative). ### Why CECT is Optimal 1. **High sensitivity and specificity** — detects splenic lacerations, active bleeding (arterial extravasation), and pseudoaneurysms 2. **Injury grading** — allows classification (Grade I–V) which correlates with management and prognosis 3. **Associated injuries** — simultaneously evaluates other intra-abdominal organs (liver, kidney, pancreas, mesentery) 4. **Non-invasive** — preserves splenic function if managed conservatively 5. **Guides management** — Grade I–III injuries can be managed non-operatively in stable patients; Grade IV–V may require intervention ### Comparison of Investigations | Investigation | Sensitivity | Specificity | Utility in Stable Patient | Grading Capability | |---|---|---|---|---| | **CECT** | 95–100% | 95–100% | Gold standard | Excellent (Grade I–V) | | **FAST** | 73–96% | High | Detects free fluid; poor for organ-specific injury | None | | **DPL** | 95%+ | Lower | Invasive; positive even with minor bleeding | None | | **Diagnostic laparoscopy** | High | High | Invasive; reserved for equivocal cases or therapeutic intent | Limited | **Clinical Pearl:** FAST is excellent for detecting free intra-peritoneal fluid (haemorrhage) in unstable patients but cannot grade splenic injury or exclude other injuries. DPL is largely obsolete in the era of CECT. **High-Yield:** In haemodynamically **stable** patients with blunt abdominal trauma, CECT is the investigation of choice. In **unstable** patients, FAST is the rapid bedside test; if positive, proceed directly to theatre without further imaging. ### Management Algorithm ```mermaid flowchart TD A[Blunt abdominal trauma + suspected splenic injury]:::outcome --> B{Haemodynamically stable?}:::decision B -->|Yes| C[CECT abdomen/pelvis]:::action B -->|No| D[FAST at bedside]:::action C --> E{Grade of injury?}:::decision E -->|Grade I-III| F[Non-operative management<br/>ICU/HDU monitoring]:::action E -->|Grade IV-V or active bleeding| G[Consider angioembolization<br/>or operative intervention]:::action D -->|Free fluid + unstable| H[Proceed to theatre]:::urgent D -->|Negative| I[CECT when stable]:::action ``` [cite:ATLS 10th Edition Ch 8]