Does a patient with a grade 3 splenic laceration due to Road Traffic Accident (RTA) require surgical intervention?

Management of Grade 3 Splenic Laceration from Road Traffic Accident

A hemodynamically stable patient with a grade 3 splenic laceration from an RTA should NOT undergo immediate surgery—non-operative management (NOM) is the first-line treatment regardless of injury grade, with angioembolization considered as an adjunct. 1, 2

Initial Assessment: Hemodynamic Status is Everything

Your immediate priority is determining hemodynamic stability, defined as systolic blood pressure ≥90 mmHg without skin vasoconstriction, altered consciousness, shortness of breath, or vasopressor requirement. 2

If hemodynamically STABLE:

• Proceed with NOM as first-line treatment 1, 2
• Obtain CT scan with IV contrast to define injury anatomy and identify associated injuries 1
• Grade 3 injuries (WSES Class II) include lacerations >3cm parenchymal depth or involving trabecular vessels 2

If hemodynamically UNSTABLE (unresponsive to resuscitation):

• Immediate operative management is mandatory 1
• NOM is absolutely contraindicated with unresponsive instability 1

The Non-Operative Management Protocol

NOM should only be attempted if your facility has: 1, 2

• 24/7 capability for emergency laparotomy
• Immediate OR availability
• Angiography/angioembolization capability (or rapid transfer system)
• ICU with continuous monitoring capacity
• Immediate access to blood products

Critical monitoring requirements: 2

• ICU admission for at least first 24 hours with continuous monitoring
• Clinical and laboratory observation with bed rest for 48-72 hours
• Serial hematocrit measurements to detect ongoing bleeding
• Monitor for abdominal compartment syndrome

Angioembolization: When and Why

For grade 3 injuries specifically, angioembolization should be strongly considered even in stable patients. 1, 2 The guidelines are explicit:

• Hemodynamically stable patients with WSES Class II lesions (grade 3) without contrast blush may be considered for prophylactic proximal embolization if risk factors for NOM failure exist (age >55, ISS >25, need for >5 units blood transfusion) 1
• If CT shows contrast blush, pseudo-aneurysm, or arteriovenous fistula, AG/AE should be performed as part of NOM 1
• Use coils rather than temporary agents 1
• AG/AE increases NOM success rates from 67% to 86-100% 1

Common pitfall: Don't wait for hemodynamic deterioration to consider angioembolization in grade 3 injuries—prophylactic embolization in stable patients with risk factors improves outcomes. 1

Absolute Contraindications to NOM

Surgery is mandatory if any of these are present: 1

• Unresponsive hemodynamic instability despite resuscitation
• Peritonitis on examination
• Hollow organ injury requiring surgery
• Bowel evisceration
• Impalement injury

When NOM Fails

Indications for conversion to surgery: 2

• Development of hemodynamic instability
• Significant drop in hematocrit requiring continuous transfusion
• Signs of persistent hemorrhage despite AG/AE
• Clinical deterioration with peritoneal signs

The failure rate for NOM without angioembolization in grade 3 injuries is significantly higher than with AG/AE, making early consideration of embolization crucial. 1

Special Considerations

Concomitant head injury: NOM should still be attempted unless the patient is unstable from intra-abdominal bleeding. 1 Don't let the presence of traumatic brain injury automatically push you toward surgery if the abdomen is stable.

Age >55 years: This is a risk factor for NOM failure in higher grade injuries, but not an absolute contraindication—consider prophylactic angioembolization. 1

Blood transfusion needs: Requiring >5 units of packed red blood cells is a risk factor for failure, but again, not an absolute contraindication if hemodynamically stable. 1

Hospital Course and Discharge

• Minimum 3-5 day hospital stay for grade 3 injuries 2
• Consider repeat CT if hematocrit drops, patient has coagulopathy, or neurologic impairment 2
• Activity restriction for 6 weeks before resuming normal activities 2
• Risk of delayed rupture is highest in first 3 weeks (0.2-0.3% incidence) 2

Bottom line: The era of mandatory splenectomy for grade 3 injuries is over. NOM with selective angioembolization achieves >80% success rates while preserving splenic immune function, reducing mortality, and shortening hospital stays compared to routine surgery. 2, 3, 4 Surgery is reserved for hemodynamic instability or NOM failure, not injury grade.