Treatment for Splenic Rupture

Hemodynamic Status Determines Management Strategy

Non-operative management (NOM) is the first-line treatment for hemodynamically stable patients with splenic rupture, regardless of injury grade, while immediate operative management is required for hemodynamically unstable patients who fail resuscitation. 1

Initial Assessment and Diagnostic Approach

Hemodynamic stability assessment is the critical first step:

Contrast-enhanced CT scan is the gold standard for hemodynamically stable or stabilized patients to define injury severity and identify associated injuries 1
E-FAST ultrasound is effective and rapid for detecting free fluid in unstable patients 1
Doppler ultrasound and contrast-enhanced ultrasound are useful for evaluating splenic vascularization and follow-up 1

Non-Operative Management (NOM) Protocol

For hemodynamically stable patients:

Indications for NOM:

Hemodynamically stable patients with blunt splenic trauma should undergo NOM as first-line treatment, irrespective of injury grade 1
NOM can be attempted even in pathologic spleens (HIV/AIDS, leukemia, infectious mononucleosis) in carefully selected stable patients 2
Patients with concomitant head trauma can undergo NOM unless instability is due to intra-abdominal bleeding 1

Required Infrastructure for NOM:

Continuous patient monitoring in high-dependency/intensive care environment 1
Immediately available operating room and trained surgeons 1
Immediate access to blood products and angiography/angioembolization (AG/AE) 1
Alternatively, rapid centralization system to transfer patients if these resources unavailable 1

Role of Angiography/Angioembolization:

AG/AE may be considered first-line intervention in stable patients with arterial blush on CT scan, regardless of injury grade 1
AG/AE should be performed in all hemodynamically stable patients with WSES grade III lesions, regardless of CT blush presence 1
AG/AE is recommended for moderate-severe lesions and vascular injuries (contrast blush, pseudoaneurysms, arteriovenous fistulas) 1

Risk Factors Requiring Intensive Monitoring:

Age above 55 years, high injury severity score (ISS), and moderate-to-severe splenic injuries are prognostic factors for NOM failure 1
These factors require heightened surveillance but are not absolute contraindications to NOM 1

Operative Management (OM) Indications

Immediate splenectomy is required for:

Absolute Indications:

Unresponsive hemodynamic instability despite resuscitation 1
Peritonitis, hollow organ injuries, bowel evisceration, or impalement 1
NOM failure with significant hematocrit drop or continuous transfusion requirements 1
Hemodynamic instability in anticoagulated patients (e.g., apixaban) where reversal is challenging 3

Relative Indications:

Moderate-severe lesions in centers without intensive monitoring capability or where AG/AE is not rapidly available 1
WSES class II-III injuries with severe traumatic brain injury, unless rescue therapy (OR and/or AG/AE) is rapidly available 1

Surgical Considerations:

Splenectomy is preferred when NOM fails; partial splenic salvage is debated and not routinely recommended 1
Laparoscopic splenectomy in acute trauma with active bleeding is not recommended 1
Hospital mortality of splenectomy is approximately 2%, with postoperative bleeding in 1.6-3% of cases 1

Special Populations

Pediatric Patients:

NOM is first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma, regardless of injury grade 1
Splenectomy should be avoided in hemodynamically stable children with isolated splenic injury 1
Contrast blush on CT is not an absolute indication for splenectomy or AG/AE in children 1

Atraumatic/Spontaneous Rupture:

Most commonly associated with hematologic malignancies (chronic myeloid leukemia), infectious mononucleosis, or coagulopathies 4, 5, 6
Hemodynamically unstable patients require immediate splenectomy 4, 5, 3
Stable patients with moderate-to-severe injuries can be offered angioembolization 4
True spontaneous rupture without underlying pathology is exceedingly rare but carries high mortality risk requiring prompt intervention 5, 6

Post-Treatment Management

Thromboprophylaxis:

Mechanical prophylaxis is safe and should be used in all patients without absolute contraindications 1
LMWH-based prophylactic anticoagulation should be started as soon as possible and may be safe in selected NOM patients 1
Splenic trauma without ongoing bleeding is not an absolute contraindication to LMWH prophylaxis 1

Follow-up Imaging:

Routine post-discharge imaging not necessary for low-grade injuries 1, 7
CT follow-up before discharge for moderate-to-severe injuries 1, 7
Post-discharge CT follow-up for patients with underlying splenic pathology, coagulopathy, or neurological impairment 1, 7, 8

Activity Restriction:

4-6 weeks for minor injuries 1, 7, 8
2-4 months for moderate-to-severe injuries 1, 7, 8

Infection Prophylaxis Post-Splenectomy:

Vaccination against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) starting no sooner than 14 days post-splenectomy 1
If discharge before 15 days, vaccinate before discharge to avoid missing immunization 1
Seasonal influenza vaccination recommended for patients over 6 months 1
Antibiotic therapy strongly considered for any sudden fever or constitutional symptoms 1

Critical Pitfalls to Avoid

Do not attempt NOM in centers lacking intensive monitoring, immediate OR access, or AG/AE capability 1
Do not delay operative intervention in hemodynamically unstable patients 1
Injury grade, free fluid extent, and contrast blush on CT do not predict NOM failure—clinical status is paramount 1
Patients on anticoagulation require individualized risk-benefit assessment, but hemodynamic instability mandates definitive surgical intervention 3
Counsel NOM patients about warning signs and advise against remaining alone during first weeks post-discharge 7, 8

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