A 32-year-old man is brought to the emergency department following a high-speed motor vehicle collision. On primary survey, he is haemodynamically stable (BP 118/76 mmHg, HR 92/min). Physical examination reveals tenderness in the left upper quadrant with mild guarding. FAST (Focused Assessment with Sonography for Trauma) shows free fluid in the splenic fossa. CT abdomen with IV contrast demonstrates a Grade III splenic laceration with active contrast extravasation. What is the most appropriate immediate management?

Explanation

## Management of Blunt Splenic Injury in Haemodynamically Stable Patients **Key Point:** Non-operative management (NOM) is the standard of care for haemodynamically stable patients with blunt splenic injury, regardless of grade, provided close monitoring and surgical backup are available. ### Rationale for Non-Operative Management 1. **Haemodynamic Stability is the Primary Criterion** - This patient is normotensive (BP 118/76) and not in shock - Grade of injury (I–V) does NOT determine management in stable patients - Even Grade IV–V injuries can be managed non-operatively if the patient remains stable 2. **Benefits of Splenic Preservation** - Maintains splenic immunological function (opsonization of encapsulated organisms) - Reduces post-splenectomy infection risk (OPSI — overwhelming post-splenectomy infection) - Avoids operative morbidity and mortality 3. **Prerequisites for Safe NOM** - Haemodynamic stability (maintained throughout observation) - ICU/high-dependency unit admission with continuous monitoring - Immediate surgical team availability - Cross-matched blood readily accessible - Serial clinical examination to detect peritonitis or deterioration - Repeat imaging if clinical deterioration occurs ### When to Convert to Operative Management | Indication | Action | |---|---| | Haemodynamic instability despite resuscitation | Splenectomy | | Peritoneal signs (rebound, guarding) | Exploratory laparotomy | | Transfusion requirement > 2–4 units | Consider operative intervention | | Deteriorating clinical status | Immediate surgery | **Clinical Pearl:** Active contrast extravasation on CT (as in this case) indicates ongoing bleeding but does NOT mandate surgery if the patient is haemodynamically stable. Splenic artery embolisation (SAE) is an adjunct in select cases but is not first-line in a stable patient with ICU support available. **High-Yield:** The shift from operative to non-operative management of splenic injury is one of the most important paradigm changes in trauma surgery over the past 20 years. Success rates for NOM exceed 90% in haemodynamically stable patients. [cite:ATLS 10th Edition, Chapter 8: Abdominal Trauma]