Splenic Injury, Blunt, Selective Nonoperative Management of

Published 2012

Level 1

Patients who have diffuse peritonitis or who are hemodynamically unstable after blunt abdominal trauma should be taken urgently for laparotomy.

Level 2

  1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury.
  2. The severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age >55 and/or the presence of associated injuries are not contraindications to a trial of nonoperative management in a hemodynamically stable patient.
  3. In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the spleen.
  4. Angiography should be considered for patients with American Association for the Surgery of Trauma (AAST) grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding.
  5. Nonoperative management of splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy.

Level 3

  1. After blunt splenic injury, clinical factors such as a persistent systemic inflammatory response, increasing/persistent abdominal pain, or an otherwise unexplained drop in hemoglobin should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury.
  2. Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients.
  3. Angiography may be used either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a risk for delayed hemorrhage.
  4. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.