What is the management for a patient with splenic trauma and severe anemia?

Management of Splenic Trauma with Hemoglobin 6.2 g/dL

Immediate Assessment and Resuscitation

This patient requires immediate blood transfusion and urgent determination of hemodynamic stability to guide definitive management—if hemodynamically unstable despite resuscitation, proceed directly to emergency splenectomy; if stable, initiate transfusion and obtain CT with contrast to assess for angioembolization. 1, 2

Hemodynamic Status Determination

• Hemodynamic instability is defined as systolic blood pressure <90 mmHg with evidence of skin vasoconstriction (cool, clammy skin, decreased capillary refill), altered consciousness, shortness of breath, OR blood pressure >90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs, OR base excess >-5 mmol/L, OR shock index >1, OR transfusion requirement of 4-6 units of packed red blood cells within 24 hours 1

• Transient responders (those showing initial response to fluid resuscitation then signs of ongoing loss) are considered unstable and require operative management 1

• A hemoglobin of 6.2 g/dL represents severe anemia and suggests significant ongoing or recent hemorrhage requiring immediate transfusion 2, 3

Management Algorithm Based on Hemodynamic Status

If Hemodynamically UNSTABLE:

Proceed immediately to emergency splenectomy 1, 2, 4

• Splenectomy is indicated when the patient remains hemodynamically unstable, shows significant drop in hematocrit, or requires continuous transfusions 1, 2

• During operative management, attempt splenic preservation (at least partial) whenever possible to reduce long-term risk of overwhelming post-splenectomy infection 1, 2

• Laparoscopic splenectomy in early trauma with active bleeding is not recommended 1

If Hemodynamically STABLE or Stabilized:

Initiate transfusion protocol and obtain repeat CT scan with IV contrast to guide angioembolization decision 2, 4

Transfusion Guidelines:

• Blood transfusion is indicated for hematocrit <20% with signs of continuing blood loss, hemodynamic instability, or evidence of inadequate tissue perfusion 2

• With hemoglobin of 6.2 g/dL (hematocrit approximately 18-19%), transfusion is clearly indicated 2, 3

• Transfuse to maintain adequate oxygen delivery and hemodynamic stability 2

CT Imaging Requirements:

• Obtain repeat CT scan to assess for contrast blush, pseudoaneurysm formation, progression of injury grade, and hemoperitoneum volume 2, 4

• CT with intravenous contrast is the gold standard for evaluating splenic trauma 1

Angioembolization Decision:

Strongly consider angioembolization for moderate (AAST grade III) or severe (AAST grade IV-V) injuries in hemodynamically stable patients 1, 2, 4

• Angioembolization should be performed when the patient remains hemodynamically stable but shows signs of persistent hemorrhage (falling hemoglobin qualifies) 1, 2

• The threshold for intervention is transfusion of 40 mL/kg of blood products within 24 hours failing to stabilize the patient hemodynamically 1, 2

• Angioembolization is indicated regardless of presence of CT blush in moderate and severe injuries 4

• Use coils rather than temporary agents when performing angioembolization 4

• Angioembolization increases non-operative management success rates from 67% to 86-100% 4

Critical Monitoring Requirements

This patient requires ICU admission with continuous monitoring for at least 24 hours 4

• Management should only occur in institutions with 24/7 capacity to perform emergency hemostatic laparotomy 4

• Serial clinical examination and laboratory monitoring with immediate access to surgery and blood products is essential 5

• Clinical and laboratory observation with bed rest for 48-72 hours 1, 2

• Monitor for signs of ongoing hemorrhage: persistent tachycardia, hypotension, continued hemoglobin drop, increasing abdominal distension 2

• Watch for abdominal compartment syndrome development 4

Failure of Non-Operative Management

Convert to splenectomy if any of the following occur: 1, 2

• Persistent hemodynamic instability despite resuscitation
• Significant continued drop in hematocrit levels
• Continuous transfusion requirements
• Development of peritonitis
• Failed angioembolization with ongoing bleeding

Common Pitfalls to Avoid

• Do not rely on blood pressure and heart rate alone as markers of hemorrhagic shock, particularly in younger patients—these may be unreliable 2

• Do not delay operative intervention in truly unstable patients attempting non-operative management—this increases mortality 1

• Do not discharge prematurely—the risk of delayed splenic rupture is highest within the first 3 weeks 4

• Do not perform non-operative management in facilities without 24/7 surgical capability, ICU monitoring, angioembolization availability, and immediate blood product access 4

Thromboprophylaxis Considerations

• Mechanical prophylaxis is safe and should be considered in all patients without absolute contraindication 1

• Splenic trauma without ongoing bleeding is not an absolute contraindication to LMWH-based prophylactic anticoagulation 1

• LMWH-based prophylactic anticoagulation should be started as soon as possible from trauma and may be safe in selected patients with blunt splenic injury undergoing non-operative management 1