A 28-year-old woman is brought to the emergency department after blunt abdominal trauma from a fall. Clinical examination reveals left upper quadrant tenderness, and CT imaging shows a Grade IV splenic laceration with active arterial bleeding. Regarding splenic trauma and its management, all of the following are correct EXCEPT:

Explanation

## Blunt Splenic Trauma Management **Key Point:** Modern trauma management of splenic injury has shifted from mandatory splenectomy to a selective, organ-preserving approach. Even high-grade splenic injuries can be managed non-operatively or with angiographic intervention in haemodynamically stable patients. ### Splenic Injury Grading & Management Algorithm ```mermaid flowchart TD A[Blunt splenic injury confirmed on CT]:::outcome --> B{Haemodynamically stable?}:::decision B -->|No, unstable| C[Resuscitation + Massive transfusion protocol]:::action C --> D{Response to resuscitation?}:::decision D -->|Yes| E[Angiographic embolization or ICU observation]:::action D -->|No| F[Splenectomy]:::urgent B -->|Yes, stable| G{Grade of injury?}:::decision G -->|Grade I-II| H[Observation + bed rest]:::action G -->|Grade III-V with active bleeding| I[Splenic artery embolization]:::action G -->|Grade V or massive extravasation| J[Consider splenectomy]:::action H --> K[Serial imaging surveillance]:::action I --> K ``` **High-Yield:** The paradigm has shifted from "Grade IV/V = automatic splenectomy" to "Grade IV/V in stable patients = attempt SAE first." Splenectomy is now reserved for: - Haemodynamic instability despite aggressive resuscitation - Failed angiographic embolization - Massive splenic disruption incompatible with preservation - Damage control laparotomy in polytrauma ### Splenic Artery Embolization (SAE) | Indication | Success Rate | Complication | |---|---|---| | Grade III–IV with active bleeding in stable patient | 85–95% | Splenic infarction (20–30%), abscess (rare) | | Pseudoaneurysm (delayed) | 95%+ | Recurrent bleeding if missed | | Arteriovenous fistula | 90%+ | Steal phenomenon (rare) | **Clinical Pearl:** SAE preserves splenic function and avoids the long-term immunocompromise of splenectomy. Even partial splenic infarction (common after distal SAE) retains sufficient immunological function. ### Post-Splenectomy Prophylaxis **Warning:** All patients undergoing splenectomy (for any reason) require: - Pneumococcal conjugate vaccine (PCV13) followed by polysaccharide vaccine (PPSV23) - Meningococcal vaccine (MenACWY and MenB) - Haemophilus influenzae type b vaccine - Annual influenza vaccination - Lifelong penicillin prophylaxis (in children; controversial in adults) **Mnemonic:** OPSI = Overwhelming Post-Splenectomy Infection (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b) ### Delayed Complications - **Splenic artery pseudoaneurysm:** occurs in 0.3–0.5% of non-operative management; presents with recurrent haematuria or haemodynamic instability; managed by angiographic embolization - **Splenic infarction:** common after distal SAE but usually asymptomatic - **Abscess formation:** rare (<1%) but serious; presents with fever and elevated inflammatory markers [cite:ATLS 10e Ch 8] [cite:American Association for the Surgery of Trauma (AAST) Splenic Injury Guidelines] [cite:Sabiston Textbook of Surgery 21e Ch 50]