A 28-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He is haemodynamically stable with a blood pressure of 110/70 mmHg and heart rate of 88 bpm. On examination, he has tenderness in the left upper quadrant with mild guarding. FAST scan shows free fluid in the left paracolic gutter. CT abdomen with IV contrast reveals a laceration of the spleen with a small amount of perisplenic fluid collection but no active extravasation. The patient remains haemodynamically stable after 2 hours of observation. What is the most appropriate next step in management?

Explanation

## Management of Blunt Splenic Injury in Haemodynamically Stable Patients ### Classification and Grading Splenic injuries are graded I–V based on depth and extent of laceration. This patient has a Grade II–III injury (small laceration with minimal fluid collection). **Key Point:** Non-operative management (NOM) is the standard of care for haemodynamically stable patients with blunt splenic injury, regardless of grade, provided there is no peritoneal signs or clinical deterioration [cite:ATLS 10th Edition, Trauma Surgery Guidelines]. ### Rationale for Conservative Management | Criterion | Finding | Implication | |-----------|---------|-------------| | **Haemodynamic stability** | BP 110/70, HR 88 | Permits observation | | **No active bleeding** | No extravasation on CT | Avoids unnecessary intervention | | **Minimal peritoneal signs** | Mild guarding only | No indication for urgent surgery | | **Imaging confirmation** | CT with IV contrast done | Baseline for serial assessment | ### Components of Non-Operative Management 1. **Bed rest and NPO status** — reduces splenic motion and minimizes risk of re-bleeding 2. **Serial clinical examination** — every 1–2 hours initially, then 4-hourly if stable; watch for signs of peritonitis or shock 3. **ICU/high-dependency unit admission** — continuous monitoring, immediate access to OR 4. **Repeat imaging** — only if clinical deterioration; routine repeat CT is not indicated 5. **Transfusion threshold** — maintain Hb >7 g/dL; avoid over-transfusion (increases intra-abdominal pressure) 6. **Activity restriction** — 6–8 weeks post-discharge to allow healing **Clinical Pearl:** Success rate of NOM in stable splenic injury is >90% in modern trauma centres. Splenectomy should be reserved for haemodynamic instability despite resuscitation, peritoneal signs, or clinical deterioration during observation. **High-Yield:** Splenic artery embolization (SAE) is reserved for: - High-grade injuries (Grade IV–V) in stable patients, OR - Pseudoaneurysm on imaging, OR - Failure of NOM (recurrent bleeding) This patient has a low-grade injury and is stable — SAE is not indicated as first-line. **Warning:** Do NOT perform diagnostic laparoscopy in blunt abdominal trauma unless there is a specific indication (e.g., penetrating flank wound with equivocal peritoneal signs). It delays definitive management and is less sensitive than CT for solid organ injury. ### Why Immediate Splenectomy Is Wrong Surgical intervention is reserved for haemodynamic instability or failure of conservative management. Removing a functioning spleen increases post-operative infection risk (especially encapsulated organisms: *Streptococcus pneumoniae*, *Haemophilus influenzae*, *Neisseria meningitidis*). This patient does not meet criteria for surgery.