Splenic Trauma AAST Grade IV with Angioembolization
medium
scissors Surgery
A 24-year-old male presents to the trauma bay after a high-speed motor vehicle collision. He is hemodynamically stable after 1 L of crystalloid resuscitation. Contrast-enhanced CT of the abdomen reveals a deep splenic laceration with perisplenic hematoma and the finding marked **B** in the diagram. Which of the following is the most appropriate next step in management?
A. Exploratory laparotomy with splenic repair
B. Immediate splenectomy in the operating room
C. Proximal splenic artery angioembolization via interventional radiology
D. Observation with serial hemoglobin monitoring and bed rest alone
Explanation
Why Proximal splenic artery angioembolization via interventional radiology is right
The finding marked B represents active contrast extravasation (blush/pseudoaneurysm) within the splenic parenchyma—a hallmark of ongoing arterial bleeding. In a hemodynamically stable patient with AAST Grade IV splenic injury, the presence of active contrast blush is the single imaging finding that mandates angioembolization rather than observation alone. Proximal splenic artery embolization reduces the risk of delayed rupture and secondary hemorrhage while preserving splenic function in a stable, responding patient. This is the standard of care per Sabiston's trauma management guidelines for Grade IV injuries with active extravasation.
Why each distractor is wrong
Immediate splenectomy in the operating room: Splenectomy is reserved for hemodynamically unstable patients who do not respond to resuscitation. This patient is stable and a responder to crystalloid, making him a candidate for non-operative management with angioembolization.
Observation with serial hemoglobin monitoring and bed rest alone: While observation is appropriate for lower-grade injuries without active bleeding, the presence of active contrast blush (marked B) indicates ongoing arterial hemorrhage. Observation alone carries unacceptable risk of delayed rupture and secondary hemorrhage in this setting.
Exploratory laparotomy with splenic repair: Splenic repair is rarely successful in deep hilar lacerations with segmental vessel involvement. It is not standard practice and carries higher morbidity than angioembolization in a hemodynamically stable patient.
High-YieldNEET PG
Active contrast blush on CT in a hemodynamically stable trauma patient mandates angioembolization, not observation or surgery.
Sabiston Textbook of Surgery, 21st Edition, Chapter 18: Management of Acute Trauma — Splenic Injury
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