What is the management of a traumatic splenic hemorrhage (bleed)?

From the Guidelines

A traumatic splenic bleed requires immediate medical attention, and the management approach should prioritize controlling life-threatening hemorrhage while considering the importance of splenic preservation for immune function and blood filtration. The initial management includes fluid resuscitation with crystalloids or blood products to maintain hemodynamic stability, along with close monitoring of vital signs 1. For hemodynamically stable patients with lower-grade splenic injuries (grades I-III), non-operative management (NOM) may be appropriate, involving bed rest, serial hemoglobin measurements, and frequent vital sign checks 1. However, hemodynamically unstable patients or those with higher-grade injuries (grades IV-V) typically require emergency surgery, which may include splenectomy or splenic repair techniques such as splenorrhaphy or partial splenectomy 1.

Key considerations in the management of traumatic splenic bleed include:

• The use of CT scan with intravenous contrast as the gold standard for diagnosing splenic injuries in hemodynamically stable patients 1
• The role of angioembolization as an adjunct to non-operative management in selected cases to control bleeding while preserving splenic tissue 1
• The importance of vaccination against encapsulated organisms and prophylactic antibiotics in patients undergoing splenectomy due to increased susceptibility to infection 1
• The need for a multidisciplinary approach to trauma management, considering both the anatomical injury and its physiologic effects 1

The management of traumatic splenic bleed should be guided by the principles of minimizing morbidity, mortality, and optimizing quality of life, with a focus on preserving splenic function whenever possible. This approach should be tailored to the individual patient's condition, taking into account factors such as hemodynamic stability, injury grade, and associated injuries 1.

From the Research

Management of Traumatic Splenic Bleed

• The management of traumatic splenic bleed has evolved over the years, with a focus on splenic preservation to reduce the risk of overwhelming post-splenectomy sepsis and transfusion-related infections 2.
• Nonoperative management (NOM) of blunt splenic trauma can be successful in hemodynamically stable patients, with a low rate of blood transfusions 2, 3.
• Splenorrhaphy, or surgical repair of the spleen, is a viable option for patients with blunt or penetrating trauma, with a high rate of splenic salvage and low mortality rate 2, 4.
• Splenic artery embolization (SAE) has become an important component of NOM, decreasing blood pressure to the spleen to allow healing while preserving splenic perfusion via collateral pathways 5.
• The choice of management depends on the patient's hemodynamic stability, injury severity, and associated injuries, with NOM preferred for stable patients and operative management for unstable patients 6, 3.

Outcomes of Management

• Studies have shown that NOM is associated with shorter hospital length of stay, fewer complications, and lower mortality rates compared to operative management 3.
• SAE has improved success rates of NOM and spleen salvage, with overall spleen salvage rates of over 85% 5.
• Complication rates are low, with rebleeding, parenchymal infarction, and abscess being the most common complications 5.
• Vaccination against common pathogens is important for patients who undergo splenectomy to mitigate infectious complications 6.