Management of Grade 5 Splenic Injury in a Hemodynamically Stable Patient

Initial Assessment and Management

For a hemodynamically stable patient with a grade 5 splenic injury and stable hemoglobin levels, non-operative management (NOM) should be attempted as the first-line treatment strategy, with close monitoring and consideration for angioembolization if there is evidence of contrast extravasation on CT scan, as recommended by the American College of Surgeons 1, 2, 3
Hemodynamic stability is the primary determinant for management approach, not the grade of splenic injury, according to the World Society of Emergency Surgery 4, 5
Even the most severe traumatic abdominal injuries (OIS grades 4-5) can benefit from NOM, provided close clinical and radiological monitoring is available, as stated by the American College of Surgeons 1, 3
NOM has become the standard of care in hemodynamically stable patients with blunt splenic trauma, with success rates of 95-100% in properly selected patients, according to the World Society of Emergency Surgery 6, 7

Patient must remain hemodynamically stable with no signs of peritonitis, as recommended by the World Society of Emergency Surgery 4, 5
Facility must have capability for continuous patient monitoring, immediate access to operating room, blood products, and trained surgeons, according to the World Society of Emergency Surgery 5, 6
Absence of other intra-abdominal injuries requiring surgical intervention, as stated by the American College of Surgeons 2, 3

Admission to intensive care unit for at least 24 hours for continuous monitoring, as recommended by the American College of Surgeons 8
Monitoring of intra-abdominal pressure to detect abdominal compartment syndrome, according to the American College of Surgeons 3, 8
Clinical and radiological reassessment as needed, as stated by the American College of Surgeons and the World Society of Emergency Surgery 3, 6

Consider urgent angioembolization if CT scan shows active contrast extravasation, even in a hemodynamically stable patient, as recommended by the American College of Surgeons and the World Society of Emergency Surgery 2, 4
Therapeutic angioembolization can significantly reduce the failure rate of NOM in splenic injuries with documented active bleeding, according to the American College of Surgeons and the World Society of Emergency Surgery 3, 5

Development of hemodynamic instability despite resuscitation, as recommended by the World Society of Emergency Surgery 4, 5
Peritonitis or evidence of hollow viscus injury, according to the World Society of Emergency Surgery 4, 7
Failure of non-operative management with continued or recurrent bleeding, as stated by the American College of Surgeons 3

Minimum hospital stay of 3-5 days for high-grade splenic injuries, as recommended by the American College of Surgeons 8
Mechanical thromboprophylaxis is safe and should be considered in all patients, according to the World Society of Emergency Surgery 4
LMWH-based prophylactic anticoagulation may be safely started as soon as possible in selected patients, as stated by the World Society of Emergency Surgery 4

The presence of contrast blush on CT scan alone is not an absolute indication for operative management if the patient remains hemodynamically stable, as recommended by the World Society of Emergency Surgery 4, 7
Concomitant injuries, especially traumatic brain injury, may complicate management decisions but do not automatically preclude NOM, according to the World Society of Emergency Surgery 7
Failure of NOM does not necessarily indicate poor initial decision-making but may be part of a staged management approach, as stated by the American College of Surgeons 3