From the Guidelines
Surgical intervention is warranted in a patient with a splenic injury when there is hemodynamic instability, as this condition is considered a critical indicator for operative management. According to the guidelines for adult and pediatric patients with splenic trauma, hemodynamic instability is defined as an admission systolic blood pressure < 90 mmHg with evidence of skin vasoconstriction, altered level of consciousness, and/or shortness of breath, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs 1.
Some key points to consider in the management of splenic injuries include:
- Hemodynamic instability is a critical indicator for surgical intervention, regardless of the grade of splenic injury.
- High-grade splenic injuries (grade IV or V) with significant parenchymal disruption or vascular injury may also require surgical intervention.
- The presence of a splenic blush on CT scan is an important predictor of failure of non-operative management (NOM), but its absence does not definitively exclude active bleeding 1.
- Angiography and angioembolization (AG/AE) may be considered in hemodynamically stable patients with moderate and severe lesions, and in those with vascular injuries at CT scan 1.
In the context of the provided scenario, hemodynamic instability is the most critical factor that warrants surgical intervention. The other options, such as Grade I splenic injury and no availability of angiography for embolization, Grade IV splenic laceration, hematocrit of 33%, and presence of splenic blush on CT scan, are important considerations in the management of splenic injuries, but they are not as critical as hemodynamic instability in determining the need for surgical intervention.
It is essential to note that the decision for operative management should be based on the patient's overall clinical condition, rather than imaging findings alone 1. Surgery typically involves either splenectomy or splenic salvage procedures, depending on the extent of injury and the patient's stability. Following splenectomy, patients require vaccination against encapsulated organisms to prevent infections.
From the Research
Findings that Warrant Surgical Intervention
- Hemodynamic instability: This is a critical condition that requires immediate surgical intervention, as it can lead to severe consequences if left untreated 2, 3, 4, 5.
- Presence of splenic blush on CT scan: This indicates active bleeding, which may require surgical intervention or angioembolization to control the bleeding 4, 5.
- Grade IV splenic laceration: This is a severe injury that may require surgical intervention, depending on the patient's condition and the presence of other injuries 2, 4.
Non-Surgical Management
- Grade I splenic injury: This is a minor injury that can often be managed non-operatively, especially if the patient is hemodynamically stable 4.
- Hematocrit of 33$: This value alone does not necessarily warrant surgical intervention, as it depends on the patient's overall condition and the presence of other injuries 6.
- Availability of angiography for embolization: This is an important consideration, as angioembolization can be a viable alternative to surgical intervention in some cases 2, 4, 5.