What is the initial treatment approach for a hemodynamically stable patient with a Grade 3 splenic injury?

Grade 3 Splenic Injury Treatment

Hemodynamically stable patients with Grade 3 splenic injury should be managed non-operatively with strong consideration for angioembolization, regardless of contrast extravasation on CT scan. 1

Initial Assessment and Stabilization

Hemodynamic stability must be confirmed before proceeding with non-operative management, defined as systolic blood pressure ≥90 mmHg without vasopressor support, skin vasoconstriction, altered consciousness, or shortness of breath. 1

• Obtain contrast-enhanced CT scan in all hemodynamically stable patients to define the anatomic injury and identify associated injuries. 1
• Grade 3 splenic injury (WSES Class II) includes lacerations >3cm parenchymal depth, subcapsular hematoma >50% surface area, or intraparenchymal hematoma >5cm. 1

Non-Operative Management Protocol

The American College of Surgeons recommends non-operative management (NOM) as first-line treatment for hemodynamically stable patients with isolated splenic injury, regardless of grade. 1 This approach has achieved success rates exceeding 80% in avoiding surgical intervention and has resulted in lower mortality rates, shorter hospital stays, and decreased post-splenectomy complications. 2

Angioembolization Decision-Making

Angiography/angioembolization (AG/AE) should be considered in ALL hemodynamically stable patients with Grade III injuries, regardless of whether CT contrast blush is present. 1 This represents a critical shift from older practice patterns.

• AG/AE should only be performed in centers where it is rapidly available (within 60 minutes). 3
• Coils are preferred over temporary agents when performing embolization. 1
• Proximal splenic artery embolization is the preferred technique for high-grade injuries. 4
• Studies demonstrate that incorporating initial SAE for high-risk patients improves NOM success rates from 77% to 97%. 5

Monitoring Requirements

All patients must be admitted to an institution with 24/7 capacity to perform emergency hemostatic laparotomy. 1

• Continuous monitoring in an intensive care unit for at least the first 24 hours is mandatory. 1
• Serial hemoglobin checks every 4-6 hours for the first 24 hours, then once or twice daily thereafter. 3
• Clinical and laboratory observation with bed rest for 48-72 hours. 1
• Monitor for intra-abdominal pressure elevation to detect abdominal compartment syndrome early. 1

Three Critical Factors Requiring Extra Caution

The World Society of Emergency Surgery consensus identified three factors that generate discrepancy in management decisions and require heightened vigilance: 2

1. Overall injury severity score - Higher ISS may warrant more aggressive intervention
2. Presence of bleeding diathesis - Coagulopathy significantly increases failure risk
3. Associated intra-abdominal injuries - May necessitate operative management regardless of splenic injury grade

Indications for Operative Management

Immediate splenectomy is indicated if:

• Hemodynamic instability develops despite resuscitation. 6
• Persistent hemorrhage occurs despite AG/AE. 1
• Significant drop in hematocrit or continuous transfusion requirement (≥5 units packed red blood cells). 3
• Associated intra-abdominal injuries requiring laparotomy are present. 3

Follow-Up Imaging

CT scan repetition during admission should be considered in patients with decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurological impairment. 1

• Routine post-discharge imaging is NOT indicated in uncomplicated cases. 3
• Ultrasound or contrast-enhanced ultrasound follow-up may be reasonable to minimize risk of life-threatening hemorrhage. 2

Common Pitfalls to Avoid

Do not perform CT scans in hemodynamically unstable patients - these patients require immediate operative management. 4

Do not delay angioembolization beyond 60 minutes in stable patients with contrast extravasation. 3

Do not discharge patients prematurely - the risk of delayed splenic rupture is highest within the first 3 weeks (incidence 0.2-0.3%). 2

Do not restrict activity for excessive periods - normal activity can resume after 6 weeks for moderate and severe injuries. 2