Management of splenic injury in the hemodynamically stable adult

CT: computed tomography; Hg: hemoglobin; Hct: hematocrit; AAST: American Association for the Surgery of Trauma.

* Examples include but are not limited to: abdominal stab or gunshot wound, pancreatic transection, bowel disruption.

¶ Examples include but are not limited to: refusal of blood transfusion, altered neurologic status precluding adequate serial abdominal examination, portal hypertension, cardiovascular or other conditions that limit the ability to tolerate bleeding.

Δ Patients with contrast extravasation or vascular blush on CT are more likely to fail observation, but if these CT findings are limited or equivocal, observation can be tried provided the patient is a candidate for observation.

◊ At the presenting facility, provided required resources are available, or at the trauma facility to which the patient has been transferred. Required resources include the ability to monitor the patient during any period of observation, provide intervention (angioembolization, surgical exploration) when indicated, and postoperative care.

§ Splenectomy is appropriate for those who are not candidates for splenic salvage (eg, cannot tolerate rebleeding, high risk for rebleeding). Splenic salvage is more likely to be tried for low-grade injuries.

¥ Patients with loss of splenic function (eg, splenectomy, splenic infarction following splenic embolization) undergo vaccination against S. pneumoniae (pneumococcus), H. influenzae type b, and N. meningitidis (meningococcus). Vaccines are administered either 14 days prior to or 14 days following splenectomy for maximal immunologic benefit.

‡ The duration of observation is individualized based upon the grade of splenic injury, nature and severity of other injuries, and the patient's clinical status. A common estimate of duration is injury grade plus one days. An observation period of five days identifies at least 95% of those who would require some form of intervention.