Grade III Splenic Injury with a Blush: Borderline Physiology and a Clock
A 26-year-old man is brought in after a high-speed motorcycle collision. He is alert, GCS 15, and complains of left upper abdominal and left shoulder tip pain. Blood pressure 96/60 mmHg, heart rate 124/min, respiratory rate 26/min, oxygen saturation 96% on room air. After 1 L of crystalloid and one unit of packed red cells his systolic pressure is 102 mmHg and heart rate 118/min. Focused assessment with sonography shows fluid in the splenorenal recess. CT with contrast shows a grade III splenic laceration with a 2 cm intraparenchymal pseudoaneurysm, no active extravasation into the peritoneum, and no other solid organ injury; there is a small amount of free fluid. Pelvis and chest imaging are normal. Haemoglobin is 92 g/L, base deficit −6 mmol/L, lactate 3.8 mmol/L, INR 1.1. He is otherwise fit with no comorbidities and takes no medication. The hospital has 24-hour interventional radiology and an operating theatre available.
1. Is he a candidate for non-operative management with angioembolisation, or should he go to theatre now? Justify your answer using his haemodynamics, CT findings and physiology, and state the criteria you would use to declare non-operative management failed.
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He is a transient responder with a high-risk CT, and the correct plan is non-operative management plus angioembolisation in a monitored setting with theatre immediately available.
Reasoning:
- The blush (pseudoaneurysm) is the single strongest predictor of failure of non-operative management in splenic trauma; angioembolisation substantially reduces that failure rate.
- He has no peritonitis, an isolated injury, GCS 15, and he stopped bleeding clinically after one unit of red cells (systolic 102 mmHg).
- However, base deficit −6 mmol/L and lactate 3.8 mmol/L show he is still in compensated shock. He is not stable; he is borderline. That is why the angiographic suite, not the ward, is the destination.
Failure criteria, i.e. convert to laparotomy:
- Systolic pressure below 90 mmHg persisting after 1–2 units of blood, or any need for more than 2 units in 24 hours.
- Continuing fall in haemoglobin with a distended abdomen.
- Peritonism or a rising base deficit despite resuscitation.
- Inability to deliver angioembolisation promptly.
Wrong answers to avoid. Sending him to the ward for observation ignores the blush. Taking a transient responder straight to theatre without attempting angioembolisation wastes a salvageable spleen, but only if IR can start now; if the radiologist were unavailable, the threshold for theatre drops sharply.
2. Forty minutes later his systolic pressure falls to 84 mmHg despite a second unit of blood and the interventional radiologist is still 45 minutes away. Outline your decision-making and the operative steps for a bleeding grade III spleen, including splenic preservation versus splenectomy and what you would check before closing.
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Decision: activate massive transfusion and go to theatre now. A systolic of 84 mmHg after two units defines a non-responder; the blush is now irrelevant because physiology has overruled imaging. Inform IR that the patient is going to theatre; do not wait 45 minutes.
Operative sequence.
- Resuscitate with balanced blood products (aim 1:1:1) and tranexamic acid; rapid transfer with the anaesthetist at the head.
- Midline laparotomy, pack all four quadrants, then remove packs systematically to localise bleeding. Left upper quadrant packing first.
- Mobilise the spleen by dividing the splenocolic and lienorenal ligaments and lifting it medially, so that the hilum can be controlled. Never blindly clamp the hilum.
- In an actively bleeding, unstable patient, splenectomy is the safer operation. Attempt splenorrhaphy with sutures and topical haemostatic agents only if there is a single accessible laceration, bleeding is controlled with a finger or sling, and the patient is stable enough for the extra time.
- Ligate the short gastric vessels and splenic artery and vein individually, remove the spleen, and inspect the pancreatic tail. A tail injury with a major duct leak may need distal pancreatectomy; a minor capsular injury can be drained.
- Copious washout, drain the left upper quadrant, close.
Before closing, check: the tail of the pancreas, the left kidney, the diaphragm, and the rest of the bowel for a missed hollow viscus injury. Give pneumococcal, Haemophilus influenzae type b and meningococcal vaccines before discharge or within 14 days.
3. Assume angioembolisation succeeded instead. Write the 48-hour observation protocol, your thromboprophylaxis plan and the follow-up imaging strategy, with the reason for each element.
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Monitoring (first 48 hours).
- High-dependency care with continuous monitoring, hourly observations and 4–6 hourly haemoglobin for the first 24 hours, then 8–12 hourly. A falling haemoglobin with tachycardia often precedes hypotension by hours.
- Serial abdominal examination by the same team, and serial base deficit or lactate; a rising lactate means ongoing bleeding regardless of blood pressure.
- Keep two large-bore cannulae and cross-matched blood available, with theatre on standby for the first 24 hours.
Thromboprophylaxis. Mechanical prophylaxis (intermittent pneumatic compression) from admission. Start low-molecular-weight heparin at 24–48 hours after embolisation, once there is no evidence of ongoing bleeding. Delayed bleeding after splenic injury is a real phenomenon and anticoagulation timing must be balanced against it; the risk of pulmonary embolism in a polytrauma patient is not trivial either.
Imaging. Image on clinical deterioration rather than on a fixed schedule. A repeat contrast CT at 48–72 hours is reasonable in higher-grade injuries, in those with a blush, or if there is a new fall in haemoglobin, to look for a growing pseudoaneurysm or delayed rupture. Duplex is not a substitute for CT here.
Discharge. Tolerating diet, pain controlled with oral analgesia, no transfusion requirement for 24 hours, and no abdominal tenderness. Give written advice about delayed rupture and a return-to-hospital instruction, and avoid contact sport for 6–8 weeks.