How should a hemodynamically stable patient with a grade III splenic laceration be managed?

Management of Grade III Splenic Laceration

Hemodynamically stable patients with grade III splenic lacerations should be managed with non-operative management (NOM) as first-line treatment, with strong consideration for prophylactic angioembolization even without CT contrast blush, as this significantly reduces length of stay and improves outcomes. 1, 2

Initial Assessment and Classification

A grade III splenic laceration is classified as WSES Class II (moderate injury) and includes:

• Subcapsular hematoma >50% surface area or expanding
• Ruptured subcapsular or parenchymal hematoma
• Intraparenchymal hematoma >5 cm
• Laceration >3 cm parenchymal depth or involving trabecular vessels 3, 1

Hemodynamic stability must be confirmed (systolic BP ≥90 mmHg without vasoconstrictors, no altered consciousness, no signs of vasoconstriction) before proceeding with NOM 1. Obtain CT scan with IV contrast to define the anatomic injury and identify associated injuries 1.

Non-Operative Management Protocol

NOM should only be attempted in facilities with specific capabilities:

• 24/7 capacity for emergency hemostatic laparotomy
• Immediate operating room availability
• Angiography/angioembolization capability rapidly available
• ICU with continuous monitoring capacity
• Immediate access to blood products 1

Monitoring requirements include:

• ICU admission for continuous monitoring for at least the first 24 hours 3, 1, 4
• Clinical and laboratory observation with bed rest for 48-72 hours 1, 4
• Serial hemoglobin/hematocrit checks every 6-8 hours initially 4
• Monitor for abdominal compartment syndrome 1

Angioembolization Decision

For grade III injuries, angioembolization should be strongly considered even in the absence of CT contrast blush. 1, 4 This recommendation is based on:

• Grade III injuries managed with angioembolization show a trend toward better outcomes with no failures compared to observation alone (0% vs 35% failure rate, p=0.070) 2
• Significant reduction in hospital length of stay (7.2 vs 10.8 days, p=0.042) for grade III injuries treated with angioembolization 2
• Overall NOM success rates exceed 80% when angioembolization is utilized 1, 5

Angioembolization is mandatory if CT demonstrates:

• Contrast blush (vascular extravasation)
• Pseudoaneurysm
• Arteriovenous fistula 1, 6

Use coils rather than temporary agents when performing angioembolization. 1

Risk Factors Requiring Heightened Vigilance

The following factors increase risk of NOM failure and warrant consideration of prophylactic angioembolization:

• Age >55 years 1
• Injury Severity Score (ISS) >25 1
• Need for >5 units blood transfusion 1
• Large hematoma size (>5 cm) 4
• Presence of significant free fluid/hemoperitoneum 4, 2

Absolute Contraindications to NOM

Proceed immediately to operative management if:

• Hemodynamic instability unresponsive to resuscitation
• Peritonitis
• Hollow organ injury
• Bowel evisceration
• Impalement injury 1

Criteria for Conversion to Surgery

Convert to splenectomy if any of the following develop:

• Hemodynamic instability despite resuscitation
• Transfusion requirement exceeding 40 mL/kg within 24 hours without stabilization
• Significant ongoing drop in hematocrit requiring continuous transfusions
• Development of peritonitis
• Failed angioembolization with continued bleeding 4

Follow-Up Imaging and Activity Restrictions

Repeat CT scan is indicated for:

• Declining hematocrit
• Clinical deterioration
• Evaluation for vascular complications (pseudoaneurysm, arteriovenous fistula)
• Patients with moderate/severe lesions, coagulopathy, or neurological impairment 1, 4

Hospital stay should be minimum 3-5 days for grade III injuries. 4 Routine post-discharge imaging is not indicated in uncomplicated cases 1.

Activity restrictions:

• Bed rest for 48-72 hours initially 1, 4
• Restrict activity for 6 weeks after discharge before resuming normal activities 1, 4
• Risk of delayed splenic rupture is highest within first 3 weeks (incidence 0.2-0.3%) 1

Thromboprophylaxis

• Initiate mechanical prophylaxis immediately (sequential compression devices)
• Consider LMWH-based prophylaxis starting 24-48 hours after injury if hemodynamically stable and no evidence of ongoing bleeding 4

Common Pitfalls to Avoid

Do not delay angioembolization if indicated - earlier intervention correlates with fewer splenectomies and reduced failure risk 6. For grade III injuries specifically, the evidence strongly supports prophylactic angioembolization given the significant reduction in length of stay and trend toward improved outcomes 2.

Do not discharge prematurely - maintain minimum 3-5 day hospital stay for grade III injuries given the risk of delayed complications 4.