Severe Splenic Injuries in Patients With Multiple Trauma.

Importance: 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. Objective: To study the treatment patterns of severe BSI and characterize clinical outcomes in patients with multiple trauma. Design, Setting, and Participants: 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. Exposures: Open splenectomy (OS), splenic angioembolization (SAE), or observation (OBS). Main Outcomes and Measures: 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). Results: 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. Conclusions and Relevance: 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.