From the Guidelines
A ruptured splenic infarct requires immediate medical attention and often surgical intervention, with operative management (OM) being the preferred treatment for hemodynamically unstable patients or those with significant hemorrhage, as recommended by the World Society of Emergency Surgery (WSES) guidelines 1. The initial management includes hemodynamic stabilization with intravenous fluids and blood transfusions as needed. For patients who are hemodynamically stable, conservative management with close monitoring in an intensive care setting may be attempted. This includes:
- Pain control with analgesics such as morphine 2-4mg IV every 4 hours as needed
- Broad-spectrum antibiotics like ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours to prevent infection
- Serial imaging with CT scans to monitor for progression However, for unstable patients or those with significant hemorrhage, emergency splenectomy is typically necessary, as stated in the WSES guidelines 1. Following splenectomy, patients require:
- Vaccinations against encapsulated organisms (pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines)
- Lifelong antibiotic prophylaxis with penicillin V 250mg twice daily or equivalent, as recommended by the WSES guidelines 1 The underlying cause of the splenic infarct should be investigated and treated, as it may result from conditions such as hematologic disorders, embolic events, or hypercoagulable states. Complications of ruptured splenic infarcts include hemorrhagic shock, peritonitis, abscess formation, and sepsis, making prompt diagnosis and treatment essential for favorable outcomes. According to the WSES guidelines, operative management should be performed in patients with hemodynamic instability and/or with associated lesions like peritonitis or bowel evisceration or impalement requiring surgical exploration 1.
From the Research
Ruptured Splenic Infarct Management
- The management of ruptured splenic infarct can be approached through different methods, including splenic artery embolization (SAE) and splenectomy 2, 3.
- A study comparing SAE and splenectomy in adult trauma patients with high-grade blunt splenic injuries found that SAE was associated with lower in-hospital mortality, shorter intensive care unit length of stay, and lower transfusion requirements 2.
- Another study reviewing the literature on operative management (OM) versus nonoperative management (NOM) versus SAE for traumatic splenic injuries found that NOM provided better outcomes than OM in hemodynamically stable patients with benign abdomens 3.
Complications and Outcomes
- A study examining the risk of perioperative infection after splenic injury found that blood transfusion was the only independently significant variable associated with perioperative infection, and that splenectomy had no independent impact on the risk of infection 4.
- A study analyzing hematologic markers after splenectomy, splenic embolization, and observation for trauma found that there were significant differences in hematologic characteristics over time based on the treatment modality employed, with observed white blood cell counts being highest following splenectomy, then embolization, and finally observation 5.
- A study comparing SAE and splenectomy in terms of early in-hospital infectious complications and outcomes found that SAE was associated with a lower rate of early infectious complications, and that splenectomy was not an independent risk factor for mortality 6.
Treatment Considerations
- The choice of treatment for ruptured splenic infarct depends on various factors, including the patient's hemodynamic status, the grade of splenic injury, and the presence of other injuries 2, 3.
- SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with lower rates of in-hospital mortality, shorter intensive care unit length of stay, and lower transfusion requirements 2.
- Nonoperative management may be considered for hemodynamically stable patients with benign abdomens, as it is associated with consistently shorter hospital length of stay, fewer complications, and lower mortality than operative management 3.