CURRENT OPINION

Organ injury scaling 2018 update: Spleen,

liver, and kidney

Rosemary A. Kozar, MD, PhD, Marie Crandall, MD, Kathirkamanthan Shanmuganathan, MD,
Ben L. Zarzaur, MD, Mike Coburn, MD, Chris Cribari, MD, Krista Kaups, MD, Kevin Schuster, MD,
Gail T. Tominaga, MD, and the AAST Patient Assessment Committee, Baltimore, Maryland

AAST Continuing Medical Education Article

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Submitted: May 26, 2018, Accepted: August 10, 2018, Published online: September 5, 2018.
From the Shock Trauma (R.A.K.), University of Maryland School of Medicine, Baltimore, Maryland, University of Florida College of Medicine Jacksonville (M.C.), Jacksonville,
Florida; Shock Trauma and Department of Radiology and Nuclear Medicine (K.S.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery
(B.Z.), Indiana University School of Medicine, Indianapolis, Indiana; Scott Department of Urology (M.C.), Baylor College of Medicine, Houston, Texas; Department of Sur-
gery (C.C.), University of Colorado, Denver, Colorado; Department of Surgery (K.K.), UCSF Fresno, California; Department of Surgery (K.S.), Yale School of Medicine; New
Haven, Connecticut; and Department of Surgery (G.T.T.), Scripps Memorial Hospital La Jolla; La Jolla, California.
Address for reprints: Rosemary Kozar, MD PhD, Shock Trauma Center and the University of Maryland School of Medicine, 22 South Green St. T1R40, Baltimore, MD 21201;
email: [email protected].

DOI: 10.1097/TA.0000000000002058

J Trauma Acute Care Surg

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 J Trauma Acute Care Surg
Kozar et al. Volume 85, Number 6

as a pseudoaneurysm or arteriovenous fistula, into the OIS.4–6

I n 1989, Moore et al. on behalf of the American Association for
the Surgery of Trauma (AAST) published the Organ Injury
Scale (OIS) for spleen, liver, and kidney.1 This was then updated
Modern-day CT scanners are unable to differentiate these two
injuries, with arteriography remaining the reference standard
for spleen and liver in 1994.2 These initial classification schemes examination. Therefore, the term vascular injury may include
were based on an anatomic description of the injured organ, either a pseudoaneurysm or arteriovenous fistula. On CT scan,
scaled from 1 to 5, representing the least to most severe injury. a vascular injury appears as a focal collection of vascular con-
They have been widely used to facilitate clinical research, risk trast that decreases in attenuation with delayed imaging. Active
stratify patients for quality measures, and for billing and coding. bleeding from a vascular injury presents as vascular contrast, fo-
Since its introduction, management of solid organ injury cal, or diffuse, that increases in size or attenuation in the delayed
has continued to evolve to one based primarily on nonoperative phase of imaging. Active bleeding may be contained within the
management along with increased reliance on computed tomog- injured organ or extend beyond the injured organ into the perito-
raphy (CT) for diagnosis and classification. This revised OIS for neal cavity.7 For consistency, the same terminology for vascular
solid organ injuries is being put forth by the Patient Assessment injuries is used for all solid organs. We acknowledge that in
Committee of the AAST to reflect this change (Tables 1–3). some instances the grade may be higher based on the presence
Changes made in the 2018 revision were based on available pub- of a vascular injury than previously described based on parenchy-
lished literature and were otherwise developed by a consensus of mal injury alone. However, available literature has confirmed that
experts for grading severity and experts in the field. The OIS has the presence of a vascular injury is associated with higher failure
been reviewed and approved by the board of managers of the rates after nonoperative management.8–22 Additionally, it is possi-
AAST. The new OIS is formatted similar to the AAST Emer- ble that the higher organ injury grade may prompt intervention,
gency General Surgery grading system.3 The solid organ injury such as angioembolization, though this revision does not address
scale includes three sets of criteria to assign grade: imaging, treatment strategies.
operative and pathologic. As with the original OIS, the highest There were also a number of changes made specifically to
of the three criteria is assigned the final AAST grade. Addition- the kidney OIS to include the addition of the following as grade
ally, if multiple grade I or II injuries are present, advance one IV injuries: vascular thrombosis as a type of vascular injury;
grade for multiple injuries up to a grade III. It is recognized that segmental renal artery or vein injury; and all collecting system
pathologic grading will most likely be a function of post-mortem injuries.23,24 Grade V kidney injury now also includes a devas-
examination and that with rapid extirpation of the spleen or cularized kidney with active bleeding.24
kidney, this may result in an increased grade. In the case of the For accurate diagnosis of vascular injuries of the spleen,
liver, very rarely would the entire organ be available for exami- liver, or kidney on CT scanning, dual phase imaging to include
nation ex-vivo. both arterial and portal venous phases is recommended. Dual
The most significant change in the 2018 revision is the phase has been shown to increase the sensitivity of in the
incorporation of CT diagnosed vascular injury, defined as either diagnosis of vascular injuries, providing overall better

TABLE 1. Spleen Organ Injury Scale—2018 Revision

AAST AIS
Grade Severity Imaging Criteria (CT findings) Operative Criteria Pathologic Criteria
I 2 – Subcapsular hematoma <10% surface area – Subcapsular hematoma <10% surface area – Subcapsular hematoma <10% surface area
– Parenchymal laceration <1 cm depth – Parenchymal laceration <1 cm depth – Parenchymal laceration <1 cm depth
– Capsular tear – Capsular tear – Capsular tear
II 2 – Subcapsular hematoma 10–50% surface – Subcapsular hematoma 10–50% surface area; – Subcapsular hematoma 10–50% surface
area; intraparenchymal hematoma <5 cm intraparenchymal hematoma <5 cm area; intraparenchymal hematoma <5 cm
– Parenchymal laceration 1–3 cm – Parenchymal laceration 1–3 cm – Parenchymal laceration 1–3 cm
III 3 – Subcapsular hematoma >50% surface area; – Subcapsular hematoma >50% surface area or – Subcapsular hematoma >50% surface
ruptured subcapsular or intraparenchymal expanding; ruptured subcapsular or area; ruptured subcapsular or
hematoma ≥5 cm intraparenchymal hematoma ≥5 cm intraparenchymal hematoma ≥5 cm
– Parenchymal laceration >3 cm depth – Parenchymal laceration >3 cm depth – Parenchymal laceration >3 cm depth
IV 4 – Any injury in the presence of a splenic – Parenchymal laceration involving segmental or – Parenchymal laceration involving
vascular injury or active bleeding confined hilar vessels producing >25% devascularization segmental or hilar vessels
within splenic capsule producing >25% devascularization
– Parenchymal laceration involving segmental or –
hilar vessels producing >25% devascularization
V 5 – Any injury in the presence of splenic vascular – Hilar vascular injury which devascularizes – Hilar vascular injury which
injury with active bleeding extending beyond the spleen devascularizes the spleen
the spleen into the peritoneum
– Shattered spleen – Shattered spleen – Shattered spleen
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Active
bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.
Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.
More than one grade of splenic injury may be present and should be classified by the higher grade of injury.
Advance one grade for multiple injuries up to a grade III.

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J Trauma Acute Care Surg
Volume 85, Number 6 Kozar et al.

TABLE 2. Liver Injury Scale—2018 Revision

AAST AIS
Grade Severity Imaging Criteria (CT Findings) Operative Criteria Pathologic Criteria
I 2 – Subcapsular hematoma <10% surface area – Subcapsular hematoma <10% surface area – Subcapsular hematoma <10% surface area
– Parenchymal laceration <1 cm in depth – Parenchymal laceration <1 cm in depth – Parenchymal laceration <1 cm
Capsular tear Capsular tear
II 2 – Subcapsular hematoma 10–50% surface – Subcapsular hematoma 10–50% surface – Subcapsular hematoma 10–50% surface
area; intraparenchymal hematoma area; intraparenchymal hematoma <10 cm area; intraparenchymal hematoma
<10 cm in diameter in diameter <10 cm in diameter
– Laceration 1–3 cm in depth and – Laceration 1–3 cm in depth and – Laceration 1–3 cm depth and
≤ 10 cm length ≤ 10 cm length ≤ 10 cm length
III 3 – Subcapsular hematoma >50% surface – Subcapsular hematoma >50% surface – Subcapsular hematoma >50%-surface
area; ruptured subcapsular or area or expanding; ruptured subcapsular area; ruptured subcapsular or
parenchymal hematoma or parenchymal hematoma intraparenchymal hematoma
– Intraparenchymal hematoma >10 cm – Intraparenchymal hematoma >10 cm – Intraparenchymal hematoma >10 cm
– Laceration >3 cm depth – Laceration >3 cm in depth – Laceration >3 cm in depth
– Any injury in the presence of a liver
vascular injury or active bleeding
contained within liver parenchyma
IV 4 – Parenchymal disruption involving – Parenchymal disruption involving – Parenchymal disruption involving
25–75% of a hepatic lobe 25–75% of a hepatic lobe 25–75% of a hepatic lobe
– Active bleeding extending beyond the
liver parenchyma into the peritoneum
V 5 – Parenchymal disruption >75% of hepatic lobe – Parenchymal disruption >75% of hepatic lobe – Parenchymal disruption >75% of
– Juxtahepatic venous injury to include – Juxtahepatic venous injury to include hepatic lobe
retrohepatic vena cava and central retrohepatic vena cava and central major – Juxtahepatic venous injury to include
major hepatic veins hepatic veins retrohepatic vena cava and central major
hepatic veins

Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging, Active
bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.
Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.
More than one grade of liver injury may be present and should be classified by the higher grade of injury.
Advance one grade for multiple injuries up to a grade III.

TABLE 3. Kidney Injury Scale—2018 Revision

AAST AIS
Grade Severity Imaging Criteria (CT Findings) Operative Goals Pathologic Criteria
I 2 – Subcapsular hematoma and/or parenchymal – Nonexpanding subcapsular hematoma – Subcapsular hematoma or
contusion without laceration – Parenchymal contusion without laceration parenchymal contusion without
parenchymal laceration
II 2 – Perirenal hematoma confined to Gerota fascia – Nonexpanding perirenal hematoma – Perirenal hematoma confined
confined to Gerota fascia to Gerota fascia
– Renal parenchymal laceration ≤1 cm depth – Renal parenchymal laceration ≤1 cm depth – Renal parenchymal laceration ≤1 cm
without urinary extravasation without urinary extravasation depth without urinary extravasation
III 3 – Renal parenchymal laceration >1 cm depth without – Renal parenchymal laceration >1 cm depth – Renal parenchymal laceration >1 cm
collecting system rupture or urinary extravasation without collecting system rupture or depth without collecting system
urinary extravasation rupture or urinary extravasation
– Any injury in the presence of a kidney vascular injury –
or active bleeding contained within Gerota fascia
IV 4 – Parenchymal laceration extending into urinary – Parenchymal laceration extending into – Parenchymal laceration extending
collecting system with urinary extravasation urinary collecting system with urinary into urinary collecting system
extravasation
– Renal pelvis laceration and/or complete – Renal pelvis laceration and/or complete – Renal pelvis laceration and/or
ureteropelvic disruption ureteropelvic disruption complete ureteropelvic disruption
– Segmental renal vein or artery injury – Segmental renal vein or artery injury – Segmental renal vein or artery injury
– Active bleeding beyond Gerota fascia into the – Segmental or complete kidney infarction(s) – Segmental or complete kidney
retroperitoneum or peritoneum due to vessel thrombosis without infarction(s) due to vessel
active bleeding thrombosis without active bleeding
– Segmental or complete kidney infarction(s)
due to vessel thrombosis without active bleeding
V 5 – Main renal artery or vein laceration or – Main renal artery or vein laceration or – Main renal artery or vein laceration
avulsion of hilum avulsion of hilum or avulsion of hilum
– Devascularized kidney with active bleeding – Devascularized kidney with active bleeding – Devascularized kidney
– Shattered kidney with loss of identifiable – Shattered kidney with loss of identifiable – Shattered kidney with loss of
parenchymal renal anatomy parenchymal renal anatomy identifiable parenchymal renal anatomy

Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging.
Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.
Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.
More than one grade of kidney injury may be present and should be classified by the higher grade of injury.
Advance one grade for bilateral injuries up to Grade III.

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 J Trauma Acute Care Surg
Kozar et al. Volume 85, Number 6

diagnostic performance in evaluating solid organ injury than ei- outcomes trial: an American Association for the Surgery of Trauma multi-
ther phase alone.5,25 Additionally, when a renal injury is known institutional study. J Trauma Acute Care Surg. 2015;79(3):335–342.
10. Marmery H, Shanmuganathan K, Mirvis SE, Richard H 3rd, Sliker C,
or suspected, delayed excretory phase imaging should be ob- Miller LA, Haan JM, Witlus D, Scalea TM. Correlation of multidetector
tained as well. CT findings with splenic arteriography and surgery: prospective study in
We sincerely hope that these OIS revisions will serve as a 392 patients. J Am Coll Surg. 2008;206:685–693.
useful tool to those caring for the injured patient. The time is 11. Marmery H, Shanmuganathan K, Alexander MT, Mirvis SE. Optimization
right for validation studies to both guide further modifications of selection for nonoperative management of blunt splenic injury: com-
parison of MDCT grading systems. AJR Am J Roentgenol. 2007;189(6):
and also to guide treatment strategies to improve outcomes with 1421–1427.
patients with spleen, liver, and kidney injuries. 12. Melloul E, Denys A, Demartines N. Management of severe blunt hepatic in-
jury in the era of computed tomography and transarterial embolization: a sys-
AUTHORSHIP
tematic review and critical appraisal of the literature. J Trauma Acute Care
R.A.K. and B.Z. conceptualized the idea. R.A.K., B.Z., G.T., K.S. performed Surg. 2015;79(3):468–474.
the literature search. R.A.K., M.C., K.S., B.Z., M.C., C.C., K.K., K.S., G.T. 13. Green CS, Bulger EM, Kwan SW. Outcomes and complications of
created the grading system. R.A.K. wrote the article. M.C., K.S., B.Z., M. angioembolization for hepatic trauma: a systematic review of the literature.
C., C.C., K.K., K.S., G.T. performed critical revision. J Trauma Acute Care Surg. 2016;80(3):529–537.
14. Misselbeck TS, Teicher EJ, Cipolle MD, Pasquale MD, Shah KT,
DISCLOSURE Dangleben DA, Badellino MM. Hepatic angioembolization in trauma pa-
The authors have no conflicts of interest to report. This work received no tients: indications and complications. J Trauma. 2009;67(4):769–773.
funding. 15. Letoublon C, Morra I, Chen Y, Monnin V, Voirin D, Arvieux C. Hepatic ar-
terial embolization in the management of blunt hepatic trauma: indications
REFERENCES and complications. J Trauma. 2011;70(5):1032–1036.
1. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, 16. Lee YH, Wu CH, Wang LJ, Wong YC, Chen HW, Wang CJ, Lin BC, Hsu YP.
Champion HR, Flint LM, Gennarelli TA, Malangoni MA, Ramenofsky ML, Predictive factors for early failure of transarterial embolization in blunt
et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29(12): hepatic injury patients. Clin Radiol. 2014;69(12):e505–e511.
1664–1666. 17. Dugi DD 3rd, Morey AF, Gupta A, Nuss GR, Sheu GL, Pruitt JH. American
2. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Association for the Surgery of Trauma grade 4 renal injury stratification into
Champion HR. Organ injury scaling: spleen and liver (1994) revision. grades 4a (low risk) and 4b (high risk). J Urology. 2010;183(2):592–597.
J Trauma. 1995;38(3):323–324. 18. Chiron P, Hornez E, Boddaert G, Dusaud M, Bayoud Y, Molimard B, et al.
3. Shafi S, Aboutanos M, Brown C, Ciesla D, Cohen MJ, Crandall ML, Inaba K, Grade IV renal trauma management. A revision of the AAST renal injury
Miller PR, Mowery NT. American Association for the Surgery of Trauma grading scale is mandatory. Eur J Trauma Emerg Surg. 2016;42(2):237–241.
Committee on patient assessment and outcomes. Measuring anatomic severity 19. Keihani S, Xu Y, Presson AP, Hotaling JM, Nirula R, Piotrowski J,
of disease in emergency general surgery. J Trauma Acute Care Surg. 2014;76: Dodgion CM, Black CM, Mukherjee K, Morris BJ, et al. Contemporary
884–887. management of high-grade renal trauma: results from the American
4. Saksobhavivat N, Shanmuganathan K, Chen HH, DuBose JJ, Richard H, Association for the Surgery of Trauma genitourinary trauma study.
Khan MA, Menaker J, Mirvis SE, Scalea TM. Blunt splenic injury: use of J Trauma Acute Care Surg. 2018;84(3):418–425.
a multidetector CT-based splenic injury grading system and clinical parame- 20. Charbit J, Manzanera J, Millet I, Roustan JP, Chardon P, Taourel P,
ters for triage of patients at admission. Radiology. 2015;274:702–711. Capdevila X. What are the specific computed tomography scan criteria that
5. Boscak AR, Shanmuganathan K, Mirvis SE, Fleiter TR, Miller LA, can predict or exclude the need for renal angioembolization after high-grade
Sliker CW, Steenburg SD, Alexander M. Optimizing trauma multidetector renal trauma in a conservative management strategy? J Trauma. 2011;70(5):
CT protocol for blunt splenic injury: need for arterial and portal venous 1219–1128.
phase scans. Radiology. 2013;268(1):79–88. 21. Nuss GR, Morey AF, Jenkins AC, Pruitt JH, Dugi DD 3rd, Morse B,
6. Gavant ML, Schurr M, Flick PA, Croce MA, Fabian TC, Gold RE. Shariat SF. Radiographic predictors of need for angiographic emboliza-
Predicting clinical outcome of nonsurgical management of blunt splenic in- tion after traumatic renal injury. J Trauma. 2009;67(3):578–582.
jury: using CT to reveal abnormalities of splenic vasculature. AJR Am J 22. Shariat SF, Roehrborn CG, Karakiewicz PI, Dhami G, Stage KH.
Roentgenol. 1997;168:207–212. Evidence-based validation of the predictive value of the American Associ-
7. Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. ation for the Surgery of Trauma kidney injury scale. J Trauma. 2007;62(4):
Nonsurgical management of blunt splenic injury: use of CT criteria to 933–939.
select patients for splenic arteriography and potential endovascular therapy. 23. Malaeb F, Figler B, Wessells H, Voelzke B. Should blunt segmental vascular
Radiology. 2000;217:75–82. renal injuries be considered an American Association for the Surgery of
8. Zarzaur BL, Dunn JA, Leininger B, Lauerman M, Shanmuganathan K, Trauma grade 4 renal injury? J Trauma Acute Care Surg. 2014;76(2):484–487.
Kaups K, Zamary K, Hartwell JL, Bhakta A, Myers J, et al. Natural history 24. Buckley JC, McAninch JW. Revision of current American Association for
of splenic vascular abnormalities after blunt injury: a Western Trauma the Surgery of Trauma renal injury grading system. J Trauma. 2011;70(1):
Association Multicenter trial. J Trauma Acute Care Surg. 2017;83(6): 35–37.
999–1005. 25. Uyeda JW, LeBedis CA, Penn DR, Soto JA, Anderson SW. Active hemor-
9. Zarzaur BL, Kozar R, Myers JG, Claridge JA, Scalea TM, Neideen TA, rhage and vascular injuries in splenic trauma: utility of the arterial phase in
Maung AA, Alacon L, Corcos A, Kerwin A, et al. The splenic injury multidetector CT. Radiology. 2014;270(1):99–106.

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