What is the preferred management for a hemodynamically unstable patient with suspected splenic injury?

• A. Nonoperative management with close monitoring
• B. Emergent operative management (splenorrhaphy or splenectomy) or exploratory laparotomy; unstable patients go to OR
• C. Angioembolization as first line
• D. Observation in the ICU

Answer: (B)

When there is hemodynamic instability with a suspected splenic injury, the priority is rapid surgical control of the bleeding. The instability means the patient is not tolerating ongoing hemorrhage, so nonoperative approaches or time-consuming imaging are not appropriate. Emergent operative management is needed to quickly access the abdomen and control the source of bleeding.

During the operation, the surgeon performs an exploratory laparotomy and decides between splenorrhaphy (repair to salvage the spleen) or splenectomy (removal of the spleen) based on the extent of injury and the patient’s condition. In many unstable cases, rapid splenectomy is required to stop bleeding and stabilize the patient.

Angioembolization and observation in the ICU are valuable tools for stable patients or as adjuncts in select scenarios, but they are not first-line for a patient who is hemodynamically unstable.