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

Management of Splenic Laceration

Non-operative management (NOM) is the first-line treatment for all hemodynamically stable patients with splenic laceration, regardless of injury grade, with success rates of 90-100% in appropriate settings. 1

Initial Assessment and Hemodynamic Status

The cornerstone of management is determining hemodynamic stability, defined as:

• Systolic blood pressure ≥90 mmHg without signs of skin vasoconstriction, altered consciousness, or shortness of breath 1, 2
• No requirement for vasopressor support or continuous transfusions 1
• Appropriate response to initial fluid resuscitation 1

Hemodynamically unstable patients require immediate operative intervention—this is non-negotiable. 1, 3

Diagnostic Approach

For hemodynamically stable patients:

• Contrast-enhanced CT scan is the gold standard with 96-100% sensitivity and specificity for splenic injuries 1, 2
• E-FAST has 91% sensitivity but 42% false-negative rate, making it useful only for unstable patients who cannot undergo CT 1
• Doppler ultrasound and contrast-enhanced ultrasound are valuable for evaluating splenic vascularization and follow-up 1, 4

Critical finding: The presence of contrast blush (active extravasation) on CT occurs in 17% of cases and predicts >60% failure rate of NOM alone—this mandates consideration of angioembolization. 1

Non-Operative Management Protocol

NOM should only be attempted in facilities with:

• 24/7 availability of operating room and trained surgeons 1, 2
• Immediate access to angiography/angioembolization (AG/AE) 1, 2
• Continuous monitoring capability in ICU setting 1, 2
• Immediate blood product availability 1

Monitoring Requirements:

• ICU admission for at least first 24 hours with continuous monitoring 2, 4
• Clinical and laboratory observation with bed rest for 48-72 hours 2, 4
• Serial hematocrit measurements to detect ongoing bleeding 2
• ICU stay required for moderate-severe lesions (Grade III-IV) 1

Role of Angioembolization

Angioembolization should be considered as first-line intervention in hemodynamically stable patients with arterial blush on CT, irrespective of injury grade. 1, 2

For WSES Grade III (Class II) injuries:

• AG/AE should be considered in all hemodynamically stable patients with Grade III lesions, even without CT blush 2
• Coils are preferred over temporary agents when performing AG/AE 2
• AG/AE is now considered part of the NOM toolkit rather than a failure of conservative management 1

Absolute Contraindications to NOM

NOM is contraindicated in:

• Hemodynamic instability unresponsive to resuscitation 1
• Peritonitis on examination 1
• Bowel evisceration or impalement 1
• Other injuries requiring laparotomy (hollow viscus injury) 1

High-Risk Factors Requiring Intensive Monitoring

Strong evidence exists that these factors predict NOM failure and require heightened vigilance:

• Age >55 years 1, 2
• High Injury Severity Score (ISS) 1, 2
• Moderate-severe splenic injuries (Grade III-IV) 1, 2

Additional risk factors to consider (not absolute contraindications):

• Large hemoperitoneum 1
• Low admission hematocrit 1
• Associated traumatic brain injury (GCS <12) 1
• Anticoagulation therapy 1

Special consideration: In patients with severe traumatic brain injury and WSES Grade II-III splenic injury, NOM can only be considered if rescue therapy (OR and/or AG/AE) is immediately available; otherwise, splenectomy should be performed. 1

Operative Management

Indications for immediate or delayed surgery:

• Hemodynamic instability despite resuscitation 1, 3
• Failure of NOM with persistent hemorrhage despite AG/AE 2, 3
• Significant drop in hematocrit requiring continuous transfusions 2
• Development of peritonitis or other surgical complications 1

Damage control surgery approach for unstable patients:

• Splenic packing with negative pressure dressing 3
• Followed by angiography with embolization if bleeding persists 3
• Splenectomy only as definitive lifesaving maneuver if surgical bleeding continues 3

Follow-Up and Discharge Planning

• Repeat CT scan should be considered for patients with moderate-severe lesions, decreasing hematocrit, vascular anomalies, or coagulopathy 2, 4
• Routine post-discharge imaging is not indicated in uncomplicated cases 2
• Risk of delayed splenic rupture is highest within first 3 weeks (0.2-0.3% incidence)—patients should not be discharged prematurely 2
• Normal activity can resume after 6 weeks for moderate-severe injuries 2

Pediatric Considerations

In children, NOM is even more successful (95-100% success rate) and splenectomy should be avoided in hemodynamically stable children with isolated splenic injury. 1

Key differences in pediatric management:

• Contrast blush on CT is not an absolute indication for splenectomy or AG/AE in children 1
• ICU admission may only be required for moderate-severe lesions 1
• Low-dose CT protocols preferred (3-6 mSv vs 11-24 mSv) to minimize radiation exposure 1
• Insufficient data exists for NOM in pediatric penetrating splenic injury 1

Common Pitfalls to Avoid

• Do not rely solely on CT grade to guide management—hemodynamic status is paramount 1, 5
• Do not attempt NOM in facilities without immediate surgical backup and angiography capability 1
• Do not ignore contrast blush on CT—this requires AG/AE consideration even if patient appears stable 1, 2
• Do not discharge patients too early—delayed rupture risk persists for 3 weeks 2