Nonoperative management of the ruptured spleen: a revalidation of criteria. 
Our goal was to revalidate this institution's original criteria for safe nonoperative management of splenic injury.  This was a prospective series between October 1991 and December 1995 entering all patients with splenic injury to a modified algorithm.  Patients were taken to the operating room if hemodynamically unstable (systolic blood pressure less than 90 mm Hg; pulse greater than 110 beats per minute) after 2 liters of fluid resuscitation, positive abdominal examination findings, American Association for the Surgery of Trauma Organ Injury Scale Grade IV or V injuries by computed tomographic scan (unless younger than 15 years old), or associated severe head injuries (unless younger than 15 years old), or age greater than 55.  The remainder of the patients were closely observed.  One hundred seventy-three patients were entered-six were excluded by death before operating room salvage, and one was excluded because of operation for a ruptured thoracic aorta.  Therefore 166 patients were reviewed.  Seventy splenectomies and 18 splenorrhaphies were performed, and 78 patients were treated nonoperatively (58% splenic salvage).  Two failures occurred in the nonoperative group: a 16-year-old with a grade IV hilar injury was operated on on the eighth day after injury because of a continually falling hematocrit, and a 25-year-old with unresolved tachycardia was operated on at 6 hours (97% success rate).  The patients in the operative group had a greater severity of injury as determined by mean Injury Severity Score of 32, 18 deaths, a mean transfusion requirement of 14 units of blood compared with mean injury severity score of 21, two deaths from brain injury, and no transfusions given in 58 of the 78 nonoperative cases.  Prospectively applied, these guidelines allow the safe nonoperative management of patients with blunt splenic injury.