Management of Grade 3 Splenic Laceration

Assessment and Classification

• The World Society of Emergency Surgery (WSES) classifies grade 3 splenic laceration as a class II injury, characterized by subcapsular hematoma >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma >5cm, or laceration >3cm parenchymal depth or involving trabecular vessels 1
• Hemodynamic stability is defined as systolic blood pressure ≥90 mmHg without signs of skin vasoconstriction, altered consciousness, shortness of breath, or requiring vasopressor support 2
• A CT scan with intravenous contrast should be performed in hemodynamically stable patients to define the anatomic splenic injury and identify associated injuries 3

Management Algorithm

• The American College of Surgeons recommends non-operative management (NOM) as the first-line approach for hemodynamically stable patients with isolated splenic injury, regardless of injury grade 3, 4
• Angiography/angioembolization (AG/AE) should be considered in all hemodynamically stable patients with WSES grade III lesions, regardless of the presence of CT blush 5, 6
• AG/AE should be performed as part of NOM only in centers where it is rapidly available, and coils are preferred to temporary agents when performing AG/AE 5, 6
• Monitoring requirements include admission to an institution with 24/7 capacity to perform emergency hemostatic laparotomy, continuous monitoring for at least the first 24 hours in an intensive care unit, and clinical and laboratory observation with bed rest for 48-72 hours 2, 4, 6, 7

Intervention and Surgery

• Operative management should be performed if the patient develops hemodynamic instability or shows signs of persistent hemorrhage despite AG/AE 5, 6
• Splenectomy should be performed when NOM with AG/AE fails and the patient remains hemodynamically unstable, shows significant drop in hematocrit, or requires continuous transfusion 6

Follow-up and Monitoring

• Clinical and laboratory observation with bed rest is essential in the first 48-72 hours, and CT scan repetition during admission should be considered in patients with moderate and severe lesions, decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurological impairment 6
• Monitor for intra-abdominal pressure elevation to detect abdominal compartment syndrome early 7

Grade 3 Splenic Injury Treatment Guidelines

Non-Operative Management Protocol

• The American College of Surgeons recommends non-operative management as first-line treatment for hemodynamically stable patients with isolated splenic injury, with success rates exceeding 80% in avoiding surgical intervention, resulting in lower mortality rates, shorter hospital stays, and decreased post-splenectomy complications 8, 9

Three Critical Factors Requiring Extra Caution

• The World Society of Emergency Surgery consensus identified overall injury severity score as a critical factor, where higher ISS may warrant more aggressive intervention 8, 9, 10

Follow-Up and Post-Discharge Care

• Routine post-discharge imaging is not indicated in uncomplicated cases, but ultrasound or contrast-enhanced ultrasound follow-up may be reasonable to minimize risk of life-threatening hemorrhage 10
• Patients should not be discharged prematurely, as the risk of delayed splenic rupture is highest within the first 3 weeks, with an incidence of 0.2-0.3% 10
• Normal activity can resume after 6 weeks for moderate and severe injuries 10

Management of Grade 3 Splenic Laceration

Initial Assessment and Management

• A hemodynamically stable patient with a grade 3 splenic laceration from a road traffic accident should undergo non-operative management (NOM) as the first-line treatment, with angioembolization considered as an adjunct, according to the World Journal of Emergency Surgery guidelines 11, 12
• The American College of Surgeons recommends that hemodynamically stable patients with grade 3 splenic lacerations should proceed with NOM, obtain a CT scan with IV contrast, and consider angioembolization if risk factors for NOM failure exist 11, 12
• Immediate operative management is mandatory for hemodynamically unstable patients, and NOM is absolutely contraindicated in cases of unresponsive instability 11, 12

Non-Operative Management Protocol

• The Eastern Association for the Surgery of Trauma recommends that NOM should only be attempted if the facility has 24/7 capability for emergency laparotomy, immediate OR availability, angiography/angioembolization capability, ICU with continuous monitoring capacity, and immediate access to blood products 11
• The Western Trauma Association guidelines suggest that critical monitoring requirements for NOM include ICU admission for at least the first 24 hours with continuous monitoring, and monitoring for abdominal compartment syndrome 11

Angioembolization

• The World Society of Emergency Surgery recommends that angioembolization should be strongly considered for grade 3 injuries, even in stable patients, if risk factors for NOM failure exist, such as age >55, ISS >25, or need for >5 units blood transfusion 13, 14
• The Society of Interventional Radiology guidelines state that if CT shows contrast blush, pseudo-aneurysm, or arteriovenous fistula, angioembolization should be performed as part of NOM 15, 13, 12
• The use of coils rather than temporary agents is recommended for angioembolization 13, 14
• Angioembolization increases NOM success rates from 67% to 86-100% 15

Absolute Contraindications to NOM

• The American College of Surgeons recommends that surgery is mandatory if there is unresponsive hemodynamic instability, peritonitis, hollow organ injury, bowel evisceration, or impalement injury 11, 12

Special Considerations

• The Eastern Association for the Surgery of Trauma guidelines suggest that NOM should still be attempted in patients with concomitant head injury unless the patient is unstable from intra-abdominal bleeding 11, 12
• The Western Trauma Association recommends that age >55 years is a risk factor for NOM failure, but not an absolute contraindication, and prophylactic angioembolization should be considered 13, 14
• The Society of Critical Care Medicine guidelines state that requiring >5 units of packed red blood cells is a risk factor for failure, but not an absolute contraindication if hemodynamically stable 13, 14

Risk Factors and Failure Rates in Non‑Operative Management of Splenic Laceration

High‑Risk Factors (World Society of Emergency Surgery consensus)

• Patients with an overall injury severity score > 25 are considered high‑risk and may warrant prophylactic splenic angioembolization even in the absence of contrast blush on CT. 16
• The presence of a bleeding diathesis or coagulopathy identifies a high‑risk subgroup that requires intensive monitoring and a lower threshold for operative or endovascular intervention. 16
• Concurrent intra‑abdominal injuries increase the likelihood that operative management will be needed despite an otherwise manageable splenic injury. 16

Non‑Operative Management (NOM) Failure Rates (World Society of Emergency Surgery data)

• Re‑bleeding occurs in approximately 16 % of patients managed with NOM alone, typically around 2.3 days after admission. 16
• When splenic angioembolization is performed, the re‑bleeding rate rises to about 28 %, with a median time to re‑bleeding of 2.0 days. 16
• Injuries graded III–V are associated with a 15.6‑fold increase in the odds of NOM failure compared with lower‑grade injuries. 16