From the Guidelines
Splenic laceration treatment should prioritize non-operative management (NOM) for hemodynamically stable patients with minor to moderate injuries, while emergency surgical intervention is necessary for severe lacerations or hemodynamically unstable patients. The management of splenic trauma has evolved to favor NOM, which includes hospital admission, bed rest, close monitoring of vital signs, serial hemoglobin measurements, and possibly serial abdominal imaging 1. This approach is successful in 80-90% of cases, as the spleen has remarkable healing capabilities.
Key Considerations
- For minor lacerations (grade I-II) in stable patients, NOM is recommended, involving hospital admission, bed rest, close monitoring of vital signs, serial hemoglobin measurements, and possibly serial abdominal imaging.
- For severe lacerations (grade III-V) or hemodynamically unstable patients, emergency surgical intervention is necessary, which may include splenectomy (complete removal) or splenic salvage procedures like partial splenectomy or splenic artery embolization.
- Following splenectomy, patients require vaccinations against encapsulated organisms (pneumococcus, meningococcus, and Haemophilus influenzae type B) and lifelong antibiotic prophylaxis due to increased susceptibility to infections.
- The spleen's importance in immune function makes preservation preferable when possible, as it filters blood and helps fight certain infections.
Diagnostic Procedures
- The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient 1.
- E-FAST is effective and rapid to detect free fluid, while CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients 1.
- Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up 1.
Non-Operative Management
- NOM is recommended as first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma 1.
- Patients with moderate-severe blunt and all penetrating splenic injuries should be considered for transfer to dedicated pediatric trauma centers after hemodynamic stabilization 1.
- 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 1.
Operative Management
- OM should be performed in patients with hemodynamic instability and absence of other abdominal organ injuries requiring surgery 1.
- 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 1.
- During OM, salvage of at least a part of the spleen is debated and could not be suggested 1.
From the Research
Splenic Laceration Management
- The management of splenic lacerations can be either operative or nonoperative, with the choice depending on the patient's hemodynamic stability and the grade of injury 2, 3.
- Nonoperative management (NOM) is preferred for hemodynamically stable patients with benign abdomens, as it results in shorter hospital stays, fewer complications, and lower mortality rates compared to operative management (OM) 2.
- Splenic artery embolization (SAE) is a key component of NOM for high-grade splenic injuries, and it has improved the success rates of NOM and spleen salvage 4.
Indications for Operative Management
- Hemodynamic instability and peritonitis are indications for emergent splenectomy 3.
- The decision to operate is also influenced by the patient's age, associated injuries, and splenic CT findings 3.
Nonoperative Management
- Close monitoring is required for patients selected for nonoperative management, including interval CT scans for high-grade injuries 3.
- Nursing observations are crucial in identifying patients who may require surgical intervention, with signs such as uncontrolled pain, skin color and temperature changes, and serial hemoglobin level changes being indicative of potential complications 5.