What is the initial management approach for a patient with a splenic laceration?

From the Guidelines

The initial management of a splenic laceration should focus on hemodynamic stabilization and assessment of injury severity, with non-operative management (NOM) preferred for hemodynamically stable patients with lower-grade lacerations (grades I-III) and operative management (OM) for hemodynamically unstable patients or those with higher-grade injuries (grades IV-V). The management approach is based on the World Journal of Emergency Surgery guidelines 1, which recommend NOM as the first-line treatment for hemodynamically stable patients with blunt splenic trauma, and OM for patients with hemodynamic instability or other indications for laparotomy. Key considerations in the management of splenic lacerations include:

• Hemodynamic stabilization with crystalloid fluids and blood products as needed
• Assessment of injury severity using abdominal CT scan with IV contrast
• Close monitoring in an intensive care setting for patients with lower-grade lacerations
• Immediate surgical intervention, including exploratory laparotomy and possible splenectomy, for hemodynamically unstable patients or those with higher-grade injuries
• Pain management with medications such as morphine or hydromorphone
• Continuous vital sign monitoring to detect early signs of hemorrhagic shock The goal of management is to preserve splenic function whenever possible while balancing the risk of life-threatening hemorrhage that can occur with higher-grade injuries. According to the guidelines, NOM should only be attempted in centers capable of precise diagnosis and intensive management, and OM should be performed in patients with hemodynamic instability or other indications for laparotomy 1. Additionally, the guidelines recommend the use of CT scan with intravenous contrast to define the anatomic spleen injury and identify associated injuries, and angiography and embolization (AG/AE) may be considered in patients with hemodynamic stability and arterial blush on CT scan 1. Overall, the management of splenic lacerations requires a multidisciplinary approach and careful consideration of the patient's individual needs and circumstances.

From the Research

Initial Management Approach

The initial management approach for a patient with a splenic laceration depends on various factors, including the patient's hemodynamic stability, the grade of the injury, and the presence of other injuries.

• Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography 2.
• The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management 2.
• Angioembolization might help to increase the nonoperative management rates, as well as nonoperative management success rates 3.

Nonoperative Management

Nonoperative management (NOM) of hemodynamically stable patients with blunt splenic injury (BSI) is the standard of care, although it is associated with a potential risk of failure.

• The success rate of NOM was 95.8% in one series, with an overall rate of successful NOM of 70% among all BSI cases 3.
• The criteria for nonoperative management are controversial, and the preference for a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity 4.
• Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt splenic injury, with no difference in in-hospital mortality between the two groups 5.

Predictors of Nonoperative Management Failure

Independent predictors of failed nonoperative management include:

• The presence of a bleeding disorder
• Early blood transfusion requirement
• Grade V injury 5.
• Splenic artery embolization is associated with a decreased risk of nonoperative management failure 5.

Comparison with Immediate Splenectomy

Nonoperative management is compared to immediate splenectomy in terms of outcomes, including in-hospital mortality, infectious complications, and hospitalization length.

• In-hospital mortality was not different between the immediate splenectomy and nonoperative management patients, although immediate splenectomy patients had a higher incidence of infectious complications 5.
• Patients who had failed nonoperative management had a lower in-hospital mortality rate than immediate splenectomy patients, but required longer hospitalization 5.