A 28-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was the driver and struck a tree at 80 km/h. On arrival, his vital signs are BP 110/70 mmHg, HR 102/min, RR 20/min. Abdominal examination reveals tenderness in the left upper quadrant with guarding. FAST scan shows free fluid in the left paracolic gutter and around the spleen. Contrast-enhanced CT abdomen shows a laceration of the splenic parenchyma with active extravasation of contrast. There is no peritoneal penetration. What is the most appropriate next step in management?

Explanation

## Management of Blunt Splenic Injury ### Current Evidence for Non-Operative Management **Key Point:** Non-operative management (NOM) is now the standard of care for haemodynamically stable patients with blunt splenic injury, regardless of injury grade, provided close monitoring and surgical backup are available [cite:ATLS 10th Edition]. ### Indications for Non-Operative Management - Haemodynamic stability (BP >90 mmHg systolic, HR <120/min) - Absence of peritoneal signs requiring laparotomy - Availability of ICU/high-dependency unit monitoring - Immediate access to operating theatre and blood products - Reliable patient for serial examination ### Management Protocol | Phase | Action | |-------|--------| | **Admission** | ICU/HDU admission, continuous monitoring, IV access, cross-matched blood | | **First 24–48 hours** | Bed rest, serial abdominal examination q2–4h, serial haemoglobin | | **Days 2–7** | Gradual mobilization if stable, repeat imaging only if clinical deterioration | | **Week 2 onwards** | Discharge with activity restriction (4–6 weeks) | **High-Yield:** Success rate of NOM in haemodynamically stable patients is >90%, even with high-grade injuries (Grade IV–V). Spleen preservation maintains post-traumatic immune function and avoids operative morbidity. ### Indications for Conversion to Surgery 1. Haemodynamic instability despite resuscitation 2. Peritoneal signs (rebound, rigidity) suggesting other injuries 3. Decreasing haemoglobin despite transfusion 4. Deteriorating clinical status ### Role of Angiographic Embolization **Clinical Pearl:** Splenic artery embolization (SAE) is an adjunct in selected cases: - High-grade injuries (Grade IV–V) with active extravasation - Pseudoaneurysm formation - Failure of conservative management - Used as "damage control" to avoid splenectomy However, in this haemodynamically stable patient with a single laceration, NOM with monitoring is first-line; SAE is reserved for those with imaging evidence of pseudoaneurysm or recurrent bleeding. ### Why This Patient Qualifies for NOM - BP 110/70 mmHg (stable) - HR 102/min (acceptable) - No peritoneal penetration - No other injuries mentioned - Alert and reliable for examination --- ## Summary Algorithm ```mermaid flowchart TD A[Blunt splenic injury on imaging]:::outcome --> B{Haemodynamically stable?}:::decision B -->|No| C[Resuscitate]:::action C --> D{Response to fluids?}:::decision D -->|No| E[Splenectomy]:::urgent D -->|Yes| F[Reassess stability] B -->|Yes| G{Peritoneal signs or other injuries?}:::decision G -->|Yes| E G -->|No| H[Non-operative management]:::action H --> I[ICU/HDU, serial exam, cross-matched blood]:::action I --> J{Clinical deterioration?}:::decision J -->|Yes| E J -->|No| K[Discharge with activity restriction]:::outcome ```