A 24-year-old man arrives at the trauma centre hemodynamically stable (BP 110/70, HR 105) following a motor vehicle collision. He complains of left upper quadrant pain and left shoulder pain (Kehr sign). Trauma CT demonstrates the finding marked **A** in the diagram—a 4 cm deep splenic laceration with focal active contrast extravasation and moderate hemoperitoneum. Which of the following is the most appropriate next management step for this patient?

Explanation

## Why Splenic artery embolization (SAE) is correct The structure marked **A** represents an AAST Grade III–IV splenic injury with active contrast blush (vascular injury), which per the 2018 AAST Organ Injury Scaling is functionally upgraded to Grade IV due to the presence of pseudoaneurysm or active bleeding. The patient is hemodynamically stable (BP 110/70, HR 105), which is the critical determinant of management. In hemodynamically stable patients with high-grade injuries (Grade III–V) and evidence of vascular injury (contrast blush), the EAST Practice Management Guidelines and AAST 2018 revision recommend splenic artery embolization by interventional radiology as the first-line definitive intervention. SAE achieves splenic salvage in >90% of selected patients while preserving immune function and avoiding the lifelong risks of post-splenectomy infection (OPSI). Proximal embolization is used for diffuse injury patterns like this one. ## Why each distractor is wrong - **Immediate exploratory laparotomy and splenectomy**: This is reserved for hemodynamically unstable patients (persistent hypotension despite resuscitation, ongoing transfusion requirement) or those with contraindications to angiography. The patient is stable and is a candidate for splenic salvage. - **Nonoperative management with serial clinical examination and bed rest**: This is appropriate only for low-grade injuries (Grade I–II) without contrast blush. This patient has a high-grade injury with active vascular extravasation and requires definitive intervention. - **Observation with serial imaging every 6 hours for 48 hours**: Observation alone is inadequate for a Grade IV injury with active contrast blush and risks delayed hemorrhage, hemodynamic deterioration, and loss of the window for salvage. **High-Yield:** In hemodynamically stable patients with high-grade splenic injury and contrast blush, splenic artery embolization is the standard of care and achieves >90% splenic salvage while preserving immunity. [cite: AAST Organ Injury Scaling — Spleen 2018; EAST Practice Management Guidelines]