Management of Splenic Injuries

Initial Management Approach

Hemodynamically stable patients with any grade of splenic injury should receive non-operative management as the standard of care, with angiography/angioembolization reserved for AAST Grade IV-V injuries or any grade with contrast blush on CT scan, as recommended by the World Journal of Emergency Surgery 1, 2
Hemodynamic stability is more critical than anatomic injury grade in determining treatment strategy, with unstable patients requiring immediate operative management regardless of AAST grade 3, 4

For AAST Grade I-II injuries, observation with serial abdominal examinations and hematocrit checks every 6 hours for the first 24-72 hours is recommended, with a non-operative management success rate exceeding 95% 1, 5
For AAST Grade III injuries, non-operative management with close observation is appropriate for patients without contrast blush, with prophylactic angiography/angioembolization not recommended routinely 1, 2
For AAST Grade IV-V injuries, angiography/angioembolization is recommended if hemodynamically stable, as non-operative management failure rates are unacceptably high 1, 2

Any patient with contrast blush on CT requires angiography/angioembolization regardless of AAST grade, with non-operative management failure rates ranging from 67-82% 1, 2
Pseudoaneurysm or arteriovenous fistula requires angiography/angioembolization, with higher non-operative management failure rates 1, 2

Proceed directly to splenectomy for hemodynamic instability despite resuscitation, failed non-operative management, total splenic avulsion, or Grade IV injuries in centers without angiography/angioembolization capability 3

Earlier angiography/angioembolization correlates with fewer splenectomies and reduced failure risk, with delay increasing failure risk 1
Do not routinely embolize Grade III injuries without vascular abnormalities, as this may increase morbidity without decreasing non-operative management failure rates 1, 2