Treatment for Splenic Injuries
Non-operative management (NOM) is the first-line treatment for all hemodynamically stable patients with splenic injury, regardless of injury grade, while immediate operative management is mandatory for hemodynamically unstable patients or those with peritonitis, hollow organ injury, bowel evisceration, or impalement. 1
Initial Assessment and Triage
Hemodynamic stability determines the entire treatment pathway. Stability is defined as systolic blood pressure ≥90 mmHg without skin vasoconstriction, altered consciousness, shortness of breath, or vasopressor requirement 2. Check these parameters immediately upon presentation.
Diagnostic Imaging Based on Stability
- Hemodynamically stable patients: Obtain CT scan with intravenous contrast—this is the gold standard for defining anatomic injury and identifying associated injuries 1, 2
- Hemodynamically unstable patients: Transfer immediately to the operating room; do not delay for imaging 3
- E-FAST ultrasound: Useful for rapid detection of free fluid, but a positive E-FAST in stable patients should be followed by CT scan 1
Treatment Algorithm for Hemodynamically Stable Patients
Non-Operative Management Requirements
NOM should only be attempted in facilities with all of the following capabilities available 24/7: 1, 2
- Immediate operating room availability
- Angiography/angioembolization capability
- ICU with continuous monitoring
- Immediate access to blood products
- Trained trauma surgeons
If these resources are unavailable, transfer the patient after hemodynamic stabilization to a facility that has them. 1
Angioembolization Strategy
Angioembolization should be considered the first-line intervention in stable patients with arterial blush on CT scan, regardless of injury grade. 1, 2 This is a critical point where guidelines have evolved—you don't wait for NOM to fail.
For WSES grade III (grade 3) injuries specifically, strongly consider angioembolization even in stable patients, particularly if risk factors exist: 2
- Age >55 years
- Injury Severity Score (ISS) >25
- Need for >5 units blood transfusion
- Presence of contrast blush, pseudoaneurysm, or arteriovenous fistula on CT
Use coils rather than temporary agents when performing angioembolization. 2 This increases NOM success rates from 67% to 86-100% 2.
Monitoring Protocol During NOM
- ICU admission with continuous monitoring for at least the first 24 hours
- Clinical and laboratory observation with bed rest for 48-72 hours
- Serial hematocrit measurements
- Monitoring for abdominal compartment syndrome
For moderate-severe lesions (grades III-V), consider repeat CT scanning during admission if: 2, 5, 4
- Decreasing hematocrit
- Vascular anomalies present
- Underlying splenic pathology
- Coagulopathy
- Neurologic impairment
Treatment Algorithm for Hemodynamically Unstable Patients
Immediate operative management is mandatory. 1, 3 Transfer directly to the operating room without delay for imaging.
Damage Control Surgery Approach
The surgical strategy should prioritize splenic salvage when possible: 3
- Perform splenic packing with placement of negative pressure dressing
- Follow with angiography and embolization of ongoing arterial bleeding
- Reserve splenectomy only as a definitive lifesaving maneuver if surgical bleeding persists
Splenectomy is required when: 2, 5
- NOM with angioembolization fails
- Patient remains hemodynamically unstable
- Significant drop in hematocrit occurs
- Continuous transfusions are required
Absolute Contraindications to Non-Operative Management
NOM is absolutely contraindicated in the presence of: 1, 2
- Unresponsive hemodynamic instability
- Peritonitis
- Hollow organ injuries
- Bowel evisceration
- Impalement injury
Special Populations and Circumstances
Pediatric Patients
NOM is recommended as first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma, with success rates of 95-100%. 1 In hemodynamically stable children with isolated splenic injury, splenectomy should be avoided 1. The management principles are identical to adults, but pediatric patients have even higher NOM success rates 1.
Concomitant Head Trauma
NOM should still be attempted even with concomitant head injury, unless the patient is unstable and this might be due to intra-abdominal bleeding. 1, 2
Penetrating Trauma
Penetrating splenic injuries require more cautious approach. Patients with moderate-severe blunt and all penetrating splenic injuries should be considered for transfer to dedicated trauma centers after hemodynamic stabilization 1. There is insufficient data validating NOM for penetrating spleen injury, particularly in children 1.
Common Pitfalls to Avoid
Do not use injury grade alone to determine treatment. Injury grade on CT scan, extent of free fluid, and presence of pseudoaneurysm do not predict NOM failure or need for operative management 1. The decision is based on hemodynamic stability and facility capabilities, not CT grade.
Do not discharge patients prematurely. NOM failure rates peak at 4 hours then decline over 36 hours from admission, with 72.5% of failures occurring during the first week and 50% within the first 3-5 days 1. The risk of delayed splenic rupture is highest within the first 3 weeks 2.
Do not avoid wound exploration near the inferior costal margin unnecessarily, as this carries high risk of damaging intercostal vessels. 1
Activity Restriction and Discharge
Hospital length of stay: 6
- Low-grade injuries: 1-2 days
- High-grade injuries: 3-4 days (in absence of other injuries requiring longer stay)
- Minor injuries: 4-6 weeks
- Moderate and severe injuries: 6 weeks to 2-4 months
- Normal activity can resume after 6 weeks for moderate-severe injuries
Routine post-discharge imaging is not indicated in uncomplicated cases. 2 However, ultrasound or contrast-enhanced ultrasound follow-up may be reasonable to minimize risk of life-threatening hemorrhage 2.