Initial Treatment of Hemodynamically Stable Splenic Injury
Non-operative management (NOM) is the first-line treatment for all hemodynamically stable patients with splenic injury, regardless of AAST injury grade. 1, 2
Hemodynamic Assessment First
The treatment pathway is determined entirely by hemodynamic status, not injury grade. 2, 3
Hemodynamic stability is defined as:
- Systolic blood pressure ≥90 mmHg 1, 2
- No skin vasoconstriction (cool, clammy skin, decreased capillary refill) 1
- No altered level of consciousness or shortness of breath 1
- No vasopressor requirement 1, 2
- Base excess > -5 mmol/L 1
- Shock index ≤1 1
- Transfusion requirement <4-6 units packed red blood cells in first 24 hours 1
If unstable: Proceed immediately to operating room for splenectomy—do not delay for imaging. 2, 3
Initial Diagnostic Workup for Stable Patients
Obtain CT scan with intravenous contrast to define anatomic injury and identify associated injuries. 1, 2 This is the gold standard imaging modality. 2
Facility Requirements for NOM
NOM should only be attempted if your facility has ALL of the following immediately available 24/7: 1, 2, 4
- Operating room with trained trauma surgeons
- Angiography/angioembolization capability
- ICU with continuous monitoring capacity
- Immediate access to blood products
If these resources are not available, transfer the patient after hemodynamic stabilization. 1
Treatment Algorithm Based on CT Findings
For ANY grade injury WITH contrast blush, pseudoaneurysm, or arteriovenous fistula:
Proceed directly to angioembolization regardless of AAST grade. 1, 2, 3, 4 NOM failure rates with contrast blush reach 67-82% without intervention. 3 Use coils rather than temporary agents. 4
For AAST Grade I-II injuries WITHOUT vascular abnormalities:
- Observation with serial abdominal examinations 3
- Hematocrit checks every 6 hours for first 24-72 hours 3
- NOM success rate exceeds 95% 3
For AAST Grade III injuries WITHOUT vascular abnormalities:
Strongly consider angioembolization even without contrast blush if risk factors present: 2, 4
However, do not routinely embolize Grade III injuries without vascular abnormalities or risk factors, as this may increase morbidity without benefit. 3
For AAST Grade IV-V injuries:
Angioembolization is recommended if hemodynamically stable, as NOM failure rates are unacceptably high without intervention. 3 Earlier angioembolization correlates with fewer splenectomies and reduced failure risk. 3
Monitoring Protocol During NOM
- ICU admission with continuous monitoring for at least first 24 hours 2, 4
- Bed rest for 48-72 hours 2, 4
- Serial hematocrit measurements 2, 4
- Monitoring for abdominal compartment syndrome 4
Consider repeat CT scan during admission if: 1, 4
- Decreasing hematocrit 1, 4
- Vascular anomalies present 1, 4
- Underlying splenic pathology or coagulopathy 1, 4
- Neurologic impairment 1, 4
Absolute Contraindications to NOM
Proceed immediately to operative management if: 1, 2, 4
- Unresponsive hemodynamic instability 1, 2
- Peritonitis 1, 4
- Hollow organ injury 1, 4
- Bowel evisceration 1, 4
- Impalement 1, 4
Special Circumstances
Concomitant head trauma: NOM should still be attempted unless the patient is unstable and this might be due to intra-abdominal bleeding. 1, 2, 4
Pediatric patients: NOM is first-line treatment with 95-100% success rates in hemodynamically stable children, regardless of AAST grade. 1, 2
Common Pitfalls
- Do not let injury grade alone determine treatment—hemodynamic status is paramount. 2, 3, 5
- Do not delay angioembolization in patients with contrast blush—delay increases failure risk. 3
- Do not discharge prematurely—delayed splenic rupture risk is highest within first 3 weeks (0.2-0.3% incidence). 4, 6
- Do not perform routine post-discharge imaging in uncomplicated low-grade injuries. 1, 4
Activity Restriction
Normal activity can resume after 6 weeks for moderate-severe injuries. 2, 4