What is the management approach for a 21-year-old male patient with a grade 3 splenic hematoma (12x10x3cm), who is hemodynamically stable, has a hemoglobin level of 12.6, controlled pain, and fluid around the spleen and in the pelvis?

Management of Grade 3 Splenic Hematoma in a Hemodynamically Stable 21-Year-Old Male

This patient should be managed with non-operative management (NOM) as first-line treatment, with strong consideration for prophylactic angioembolization given the large hematoma size (12x10x3cm) and presence of free fluid, requiring ICU admission for continuous monitoring for at least 24-48 hours. 1, 2, 3

Classification and Risk Stratification

Your patient has a WSES Class II injury (hemodynamically stable AAST-OIS grade III), which is classified as a moderate splenic injury. 1 The 12x10x3cm intraparenchymal hematoma exceeds the 5cm threshold that defines grade III injury, and the presence of perisplenic and pelvic fluid indicates significant hemorrhage. 1, 3

Immediate Management Protocol

Admission and Monitoring Requirements

• Admit to ICU for continuous monitoring for at least the first 24 hours, with capability for immediate conversion to emergency laparotomy if needed. 1, 2, 3
• This management approach is only appropriate in facilities with 24/7 access to emergency operating room, interventional radiology, trained surgeons, and immediate blood product availability. 1, 2
• Maintain bed rest for 48-72 hours with serial clinical examinations and laboratory monitoring (hemoglobin/hematocrit every 6-8 hours initially). 1, 2, 3

Angioembolization Decision

Strongly consider prophylactic angioembolization even without CT contrast blush, as this is a large grade III injury with significant free fluid. 1, 2, 3 The evidence shows:

• Angioembolization should be considered first-line intervention in hemodynamically stable patients with grade III injuries, regardless of contrast blush presence. 1, 3
• For grade III injuries specifically, angioembolization reduces NOM failure rates and significantly shortens hospital length of stay (7.2 vs 10.8 days). 4
• Use coils rather than temporary agents when performing angioembolization. 3

Blood Product Management

With hemoglobin of 12.6 g/dL, immediate transfusion is not required, but maintain close monitoring. 2 Transfusion becomes indicated if:

• Hemoglobin drops below 7-8 g/dL with hemodynamic stability
• Any signs of hemodynamic instability develop
• Evidence of ongoing bleeding with declining hematocrit 2

Criteria for Conversion to Operative Management

Proceed immediately to splenectomy if any of the following develop: 1, 2, 3

• Hemodynamic instability despite resuscitation (systolic BP <90 mmHg with vasoconstriction, altered consciousness, or requiring vasopressors)
• Transfusion requirement exceeding 40 mL/kg (approximately 4-6 units) within 24 hours without hemodynamic stabilization
• Significant ongoing drop in hematocrit requiring continuous transfusions
• Development of peritonitis
• Failed angioembolization with continued bleeding

Risk Factors Requiring Heightened Vigilance

While your patient is young (21 years old), the following factors warrant intensive monitoring: 1, 3, 5

• Large hematoma size (>5cm) - this 12x10x3cm hematoma significantly increases risk
• Presence of free fluid in pelvis and around spleen
• Grade III injury has intermediate risk for NOM failure

The overall NOM success rate for grade III injuries is approximately 85-90%, but can approach 100% with appropriate use of angioembolization. 3, 4

Thromboprophylaxis

• Initiate mechanical prophylaxis immediately (sequential compression devices) - this is safe and recommended. 2
• Consider LMWH-based prophylaxis starting 24-48 hours after injury if hemodynamically stable and no evidence of ongoing bleeding. 2
• Splenic trauma without active bleeding is not an absolute contraindication to pharmacologic VTE prophylaxis. 2

Follow-Up Imaging and Activity Restrictions

• Repeat CT scan is indicated if there is declining hematocrit, clinical deterioration, or to evaluate for vascular complications (pseudoaneurysm, arteriovenous fistula). 1, 3
• Hospital stay should be minimum 3-5 days for this grade III injury with large hematoma. 6
• Restrict activity for 6 weeks after discharge before resuming normal activities, as delayed splenic rupture risk is highest in first 3 weeks (0.2-0.3% incidence). 1, 3

Common Pitfalls to Avoid

• Do not discharge prematurely - the presence of significant free fluid and large hematoma size requires extended observation beyond the typical 2-3 days for lower grade injuries. 1, 3
• Do not assume hemodynamic stability will persist - approximately 27% of patients initially managed non-operatively require intervention within 30 days, with arterial complications being key risk factors. 5
• Do not delay angioembolization if any vascular abnormality is identified on CT or if clinical deterioration occurs. 3, 4