What is the management approach for a patient with a splenic injury?

Management of Splenic Injury

The management of splenic injury should follow a hemodynamic status-based approach, with non-operative management (NOM) as the first-line treatment for hemodynamically stable patients regardless of injury grade, while operative management is reserved for hemodynamically unstable patients or those with other indications for laparotomy. 1

Initial Assessment

• Hemodynamic Status Evaluation:

  • Unstable: Systolic BP <90 mmHg with evidence of skin vasoconstriction, altered consciousness, shortness of breath
  • Transient responders: Initial response to fluid resuscitation followed by signs of ongoing loss
  • Stable: Maintains normal vital signs without significant fluid requirements

• Diagnostic Imaging:

  • E-FAST (Extended Focused Assessment with Sonography for Trauma): First-line rapid assessment to detect free fluid with sensitivity up to 91% and specificity up to 96% 1
  • CT scan with intravenous contrast: Gold standard for hemodynamically stable patients to define anatomic injury and identify associated injuries 1
  • Doppler US and contrast-enhanced US: Useful for evaluating splenic vascularization and follow-up 1

Management Algorithm

For Hemodynamically Unstable Patients:

1. Immediate operative management (OM)
2. Splenectomy is typically required (reported in 24-35% of cases) 1
3. Attempts at splenic salvage (splenorrhaphy) are rare (1-6% of cases) 1

For Hemodynamically Stable Patients:

1. Non-operative management (NOM) regardless of injury grade 1

2. NOM contraindications:

   • Peritonitis
   • Hollow organ injuries requiring surgery
   • Bowel evisceration
   • Impalement 1

3. Requirements for NOM:

   • Capability for intensive monitoring
   • Immediate access to operating room
   • Immediate access to blood products
   • Availability of angiography/angioembolization
   • Trained surgeons 1, 2

4. Consider angiography/angioembolization (AG/AE) for:

   • Active contrast extravasation on CT
   • Presence of pseudoaneurysm
   • High-grade injuries (especially grade 3-5) 1, 3

Post-Management Care

For Non-Operative Management:

• Bed rest for 48-72 hours with continuous monitoring of vital signs 2
• Hemoglobin/hematocrit checks every 6 hours 2
• Multimodal analgesia (acetaminophen, NSAIDs if no contraindications, opioids for breakthrough pain) 2
• Activity restriction: 4-6 weeks for minor injuries, 2-4 months for moderate to severe injuries 2

For Post-Splenectomy Care:

• ICU admission with continuous monitoring for 24-48 hours 2
• Vaccination against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) 14 days after splenectomy 2
• Thromboprophylaxis with mechanical methods initially, followed by LMWH when bleeding risk decreases 2
• Education about overwhelming post-splenectomy infection risk 2

Special Considerations

Pediatric Patients:

• NOM is recommended as first-line treatment for hemodynamically stable pediatric patients 1
• NOM success rate in children is 95-100% 1
• Splenectomy should be avoided in hemodynamically stable children with isolated splenic injury 1
• Contrast blush on CT is not an absolute indication for splenectomy or AG/AE in children 1

Patients with Concomitant Injuries:

• Patients with concomitant spinal and severe traumatic brain injuries may benefit from immediate splenectomy over NOM in AAST-OIS grade IV-V splenic injuries 1
• However, in centers with AG/AE capability, immediate splenectomy may not provide survival benefit regardless of injury grade 1

Complications and Follow-Up

• Post-splenectomy bleeding: 1.6-3% incidence with 20% mortality 2
• Overwhelming post-splenectomy infection (OPSI) 2
• Delayed splenic rupture: Can occur days to weeks after initial injury 2
• Overall hospital mortality of splenectomy in trauma is approximately 2% 1

The trend in splenic injury management has shifted significantly toward non-operative approaches, with recent studies showing successful NOM in up to 69% of cases 4. This approach has been associated with shorter hospital stays (5.7±4.9 days vs. 10.3±6.9 days for surgical management) and reduced transfusion requirements 4.