Nonoperative management of blunt splenic trauma is widely accepted; however, reported failure rates have ranged as high as 40%. There are few factors available to identify failures reliably. To characterize failures of nonoperative management better, we retrospectively reviewed 309 blunt splenic injuries treated at our level I trauma center over a 5-year period. Eighty-nine patients were initially managed nonoperatively (29%), and 12 patients failed this approach (13%). Upon review of the initial computed tomography scans, a hyperdense collection of contrast media in the splenic parenchyma, or "contrast blush," was noted in 8 of 12 (67%) patients who failed and in 5 of 77 (6%) of those who were successfully managed nonoperatively (p < 0.0001). These data suggest that the presence of a contrast blush is an important consideration when deciding the method for management of the splenic injury. If these results are confirmed in a prospective fashion, the failure rate of nonoperative management of blunt splenic trauma could be reduced by identification of the contrast blush.