What is the initial treatment for a Grade 3 splenic (spleen) laceration with hematoma in a hemodynamically stable patient?

Initial Treatment for Grade 3 Splenic Laceration with Hematoma in a Hemodynamically Stable Patient

Angiography/angioembolization (AG/AE) should be considered in all hemodynamically stable patients with WSES grade III lesions (which includes AAST grade III splenic lacerations), regardless of the presence of CT blush. 1

Assessment and Classification

• Grade 3 splenic laceration corresponds to a WSES class II injury, characterized by subcapsular hematoma >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma >5cm, or laceration >3cm parenchymal depth or involving trabecular vessels 1
• Initial assessment must confirm hemodynamic stability, defined as systolic blood pressure ≥90 mmHg without signs of skin vasoconstriction, altered consciousness, shortness of breath, or requiring vasopressor support 1
• CT scan with intravenous contrast should be performed in hemodynamically stable patients to define the anatomic splenic injury and identify associated injuries 1

Management Algorithm

For Hemodynamically Stable Patients:

1. Non-operative management (NOM) is the first-line approach for hemodynamically stable patients with isolated splenic injury, regardless of injury grade 1

2. Angiography/angioembolization (AG/AE) considerations:

   • AG/AE should be performed in all hemodynamically stable patients with WSES grade III lesions (including grade 3 lacerations), regardless of the presence of CT blush 1
   • AG/AE should be performed as part of NOM only in centers where it is rapidly available 1
   • In centers without immediate AG/AE availability, operative management should be considered if there are signs of ongoing bleeding 1
   • Coils are preferred to temporary agents when performing AG/AE 1

3. Monitoring requirements:

   • Admission to an institution with 24/7 capacity to perform emergency hemostatic laparotomy 1
   • Continuous monitoring for at least the first 24 hours in an intensive care unit 1
   • Clinical and laboratory observation with bed rest for 48-72 hours 1
   • Clinical and biological observation for a minimum of 3-5 days 1

For Hemodynamic Deterioration During NOM:

• Operative management should be performed if the patient develops hemodynamic instability or shows signs of persistent hemorrhage despite AG/AE 1
• Splenectomy should be performed when NOM with AG/AE fails and the patient remains hemodynamically unstable, shows significant drop in hematocrit, or requires continuous transfusion 1

Follow-up During Hospitalization

• Clinical and laboratory observation with bed rest is essential in the first 48-72 hours 1
• CT scan repetition during admission should be considered in patients with moderate and severe lesions, decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurological impairment 1
• Monitor for intra-abdominal pressure elevation to detect abdominal compartment syndrome early 1

Common Pitfalls and Caveats

• Failure to recognize ongoing bleeding may lead to delayed splenic rupture, which can occur days to weeks after initial injury 2
• Laparoscopic splenectomy is not recommended in early trauma scenarios with active bleeding 1, 3
• Patients with severe traumatic brain injury and high-grade splenic injuries may benefit from early splenectomy in centers without immediate AG/AE availability 2
• The presence of contrast blush on CT scan indicates active hemorrhage and is an important predictor of NOM failure (more than 60% of patients with blush fail NOM) 1
• Patients with underlying splenic pathology may still be candidates for NOM if hemodynamically stable, though they require closer monitoring 4

By following this algorithm, the optimal management approach for a grade 3 splenic laceration with hematoma in a hemodynamically stable patient prioritizes splenic preservation while maintaining patient safety through appropriate monitoring and readiness for intervention if needed.