# Severe Splenic Injuries in Patients With Multiple Trauma

## TL;DR

Nonoperative management of severe splenic injuries in trauma patients reduces mortality and hospital stays compared to surgery, even in hypotensive patients.

## Contribution

Demonstrates nonoperative approaches (angioembolization or observation) are safer and more effective than splenectomy for severe splenic injuries in multiple trauma patients.

## Key findings

- Nonoperative management reduced mortality, complications, and hospital length of stay compared to splenectomy.
- Patients with hypotension did not have worse outcomes with nonoperative management.
- Failure of nonoperative management led to more complications than upfront surgery.

## Abstract

This cohort study examines data from the American College of Surgeons Trauma Quality Improvement Program to analyze the treatment patterns in patients with severe blunt splenic injuries and characterize clinical outcomes.

What is the optimal approach to manage severe blunt splenic injury in patients with multiple trauma?

In this cohort study that included 12 930 patients, nonoperative management (angioembolization or observation) was associated with a reduction in mortality, morbidity, and hospital course compared with splenectomy in patients with multiple trauma. Among patients with hypotension on admission, nonoperative management showed no increase in mortality, morbidity, or hospital course, but patients for whom nonoperative management failed had more complications.

These findings underscore that splenic salvage with nonoperative management may be preferred in patients with multiple trauma and high-grade splenic injury, but the selection of patients for nonoperative management should be done carefully.

The optimal management of severe blunt splenic injuries (BSI) in patients with multiple trauma is debated. This study compares early outcomes of the 3 primary treatment approaches.

To study the treatment patterns of severe BSI and characterize clinical outcomes in patients with multiple trauma.

In this cohort study, adult patients with severe BSI were identified in the American College of Surgeons Trauma Quality Improvement Program database and excluded if the Abbreviated Injury Scale score was 2 or less for all body regions outside the abdomen. Outcomes were compared based on treatment approach. Subgroup analyses were performed in patients presenting with hypotension, normotension, and those whose initial nonoperative management (NOM) failed. The associations between intervention patterns and mortality, complications, and hospital course were examined. The database was queried for data from January 2017 to December 2022; data analysis was performed from September 2024 to January 2025.

Open splenectomy (OS), splenic angioembolization (SAE), or observation (OBS).

The primary outcome was in-hospital mortality. Secondary outcomes included a variety of complications that included acute respiratory distress syndrome (ARDS), cardiac arrest, and severe sepsis, as well as hospital and intensive care unit length of stay (LOS).

In total, 12 930 patients with multiple trauma met the inclusion criteria (median [IQR] age, 39 [26-56] years; 9259 males [71.6%] and 3671 females [28.4%]). There were 3390 patients (26.2%) who underwent OS, 2537 (19.6%) who underwent SAE, and 7003 (54.2%) in the OBS group. Multivariable regression analysis found mortality risk, compared with the OS group, was lower for SAE (hazard ratio [HR], 0.62; 95% CI, 0.49 to 0.80; P < .001) and OBS (HR, 0.61; 95% CI, 0.50 to 0.74; P < .001). SAE and OBS had fewer complications compared with OS in the overall cohort (odds ratio [OR], 0.74; 95% CI, 0.64 to 0.86; P < .001, and OR, 0.75; 95% CI, 0.66 to 0.85; P < .001, respectively). For specific complications, the OS group had more ARDS, cardiac arrest, and severe sepsis. SAE and OBS had shorter hospital LOS (β, −1.37; 95% CI, −2.03 to −0.71; P < .001, and β, −1.33; 95% CI, −1.93 to −0.74; P < .001, respectively) and intensive care unit LOS (β, −1.42; 95% CI, −1.87 to −0.96; P < .001, and β, −1.34; 95% CI, −1.75 to −0.92; P < .001, respectively). The hypotensive subgroup had no increase in mortality, complications, or hospital course. Patients for whom NOM failed had more complications compared with upfront OS (OR, 3.09; 95% CI, 2.22 to 4.30; P < .001, and OR, 1.46; 95% CI, 1.21 to 1.76; P < .001, respectively). Sensitivity analysis confirmed these associations.

This study found that splenic salvage in patients with multiple trauma was associated with decreased mortality, fewer complications, and shorter hospital course compared with splenectomy. NOM in patients presenting with hypotension showed that outcomes were not inferior, while the failure of NOM was associated with more complications. NOM should be attempted, even in patients with multiple trauma who present with hypotension.