Management of Grade 5 Splenic Injury in a Hemodynamically Stable Patient
For a hemodynamically stable patient with a grade 5 splenic injury and stable hemoglobin levels, non-operative management (NOM) should be attempted as the first-line treatment strategy, with close monitoring and consideration for angioembolization if there is evidence of contrast extravasation on CT scan. 1
Initial Assessment and Management
- Hemodynamic stability is the primary determinant for management approach, not the grade of splenic injury 1
- Even the most severe traumatic abdominal injuries (OIS grades 4-5) can benefit from NOM, provided close clinical and radiological monitoring is available 1
- NOM has become the standard of care in hemodynamically stable patients with blunt splenic trauma, with success rates of 95-100% in properly selected patients 1
Criteria for Non-Operative Management
- Patient must remain hemodynamically stable with no signs of peritonitis 1
- Facility must have capability for continuous patient monitoring, immediate access to operating room, blood products, and trained surgeons 1
- Absence of other intra-abdominal injuries requiring surgical intervention 1
- No requirement for ongoing blood transfusions (>5 units of packed red blood cells would indicate need for operative management) 2
Monitoring Protocol
- Admission to intensive care unit for at least 24 hours for continuous monitoring 1
- Serial hemoglobin checks every 4-6 hours for the first 24 hours, then once or twice daily 2
- Monitoring of intra-abdominal pressure to detect abdominal compartment syndrome 1
- Clinical and radiological reassessment as needed 1
Role of Angiography and Embolization
- Consider urgent angioembolization if CT scan shows active contrast extravasation, even in a hemodynamically stable patient 1
- Therapeutic angioembolization can significantly reduce the failure rate of NOM in splenic injuries with documented active bleeding 1
- Recommended time to start angioembolization in a stable patient with intraparenchymal contrast extravasation is within 60 minutes 2
- Proximal embolization is preferred for high-grade injuries 3
Indications for Operative Management
- Development of hemodynamic instability despite resuscitation 1
- Peritonitis or evidence of hollow viscus injury 1
- Need for five or more packed red blood cell transfusions 2
- Failure of non-operative management with continued or recurrent bleeding 1, 3
Hospital Course and Follow-up
- Minimum hospital stay of 3-5 days for high-grade splenic injuries 1, 4
- No routine post-discharge imaging is indicated if the patient remains asymptomatic 2
- Mechanical thromboprophylaxis is safe and should be considered in all patients 1
- LMWH-based prophylactic anticoagulation may be safely started as soon as possible in selected patients 1
Pitfalls and Caveats
- The presence of contrast blush on CT scan alone is not an absolute indication for operative management if the patient remains hemodynamically stable 1
- Delayed splenic hemorrhage remains a risk, with most cases occurring within 8 days of injury 4
- Concomitant injuries, especially traumatic brain injury, may complicate management decisions but do not automatically preclude NOM 1, 5
- Failure of NOM does not necessarily indicate poor initial decision-making but may be part of a staged management approach 1, 3