What is the management for a patient with a splenic laceration and decreasing hemoglobin (H/H) levels?

Management of Splenic Laceration with Decreasing Hemoglobin

A patient with splenic laceration and dropping hemoglobin requires immediate assessment of hemodynamic stability to determine whether operative management, angioembolization, or continued non-operative management is appropriate—hemodynamic instability mandates immediate splenectomy, while stable patients with falling H/H should undergo repeat CT imaging and consideration for angioembolization. 1

Initial Assessment and Risk Stratification

Hemodynamic status is the primary determinant of management, not the hemoglobin level alone. 2 The key decision point is whether the patient remains hemodynamically stable despite the falling H/H:

• Hemodynamically unstable patients (persistent hypotension, tachycardia unresponsive to resuscitation) require immediate operative management with splenectomy 1
• Hemodynamically stable patients with falling H/H warrant repeat CT imaging and consideration for angioembolization 1

A critical pitfall: blood pressure and heart rate may be unreliable markers of ongoing hemorrhage, particularly in younger patients who can compensate longer before decompensating rapidly. 1

Management Algorithm for Stable Patients with Dropping H/H

Step 1: Repeat CT Imaging

Obtain repeat CT scan to assess for:

• Contrast blush (active extravasation) 1
• Pseudoaneurysm formation 1
• Progression of injury grade 1
• Hemoperitoneum volume 1

CT repetition is specifically recommended for patients with decreasing hematocrit during admission. 1

Step 2: Consider Angioembolization

Angioembolization should be performed when:

• Patient remains hemodynamically stable but shows signs of persistent hemorrhage (falling H/H, increasing transfusion requirements) 1
• WSES grade III lesions are present, regardless of CT blush 1
• CT demonstrates contrast blush or vascular abnormalities 1

The threshold for intervention: If transfusion of 40 mL/kg of blood products within 24 hours (or more than 4 units) fails to stabilize the patient hemodynamically, proceed to operative management. 1

Step 3: Intensive Monitoring Protocol

For the first 48-72 hours, clinical and laboratory observation with bed rest is the cornerstone of management for moderate and severe lesions. 1 However, recent evidence suggests that routine scheduled hemoglobin measurements do not change management—the need for intervention is driven by hemodynamic changes, not H/H trends alone. 2

Monitor for:

• Vital sign changes (hypotension, tachycardia)
• Abdominal examination findings (increasing distension, peritoneal signs)
• Transfusion requirements
• Clinical deterioration

Operative Management Indications

Proceed immediately to splenectomy when: 1

• Hemodynamic instability persists despite resuscitation
• Significant drop in hematocrit with continuous transfusion requirements
• Non-operative management or angioembolization fails
• Peritonitis or other indications for laparotomy develop

Attempt splenic preservation (partial splenectomy or splenorrhaphy) whenever possible during operative management, even in high-grade injuries. 1 This reduces the long-term risk of overwhelming post-splenectomy infection.

Laparoscopic splenectomy is not recommended in the acute trauma setting with active bleeding. 1

Special Considerations

Transfusion Strategy

Blood transfusion should be indicated primarily for:

• Hematocrit levels lower than 20% with signs of continuing blood loss 3
• Hemodynamic instability
• Evidence of inadequate tissue perfusion

Avoid indiscriminate transfusion in hemodynamically stable patients, as this does not improve outcomes. 3

Pediatric Patients

In hemodynamically stable children without drop in hemoglobin for 24 hours, bed rest should be suggested. 1 The vast majority of pediatric patients do not require angioembolization even with moderate to severe injuries. 1

Resource-Limited Settings

Operative management should be performed in moderate and severe lesions even in stable patients when:

• Intensive monitoring cannot be performed 1
• Angioembolization is not rapidly available 1

Common Pitfalls to Avoid

1. Relying solely on hemoglobin trends rather than hemodynamic status to guide intervention—all patients requiring urgent intervention did so based on hemodynamic changes, not H/H alone 2

2. Delaying repeat imaging in patients with falling H/H—this is a specific indication for CT repetition during admission 1

3. Failing to consider angioembolization before proceeding to splenectomy in stable patients—this preserves splenic function and avoids operative morbidity 1

4. Inadequate resuscitation before declaring "hemodynamic instability"—ensure adequate fluid and blood product administration before determining that non-operative management has failed 1