What is the next step in managing a child with a 3cm splenic laceration, hypotension, and no response to 1000ml of intravenous (IV) fluid resuscitation?

From the Guidelines

The recommended approach for this child with a 3cm splenic tear and stable blood pressure of 90/60 despite fluid resuscitation is observation and conservative management (option B). This approach is supported by the guidelines for splenic trauma management in pediatric patients, which emphasize the importance of preserving the spleen to maintain immune function, particularly against encapsulated organisms 1. The fact that the child's blood pressure has remained stable after fluid administration suggests that the bleeding may be contained, and conservative management can be effective in managing the injury.

Key Considerations

• The patient's hemodynamic stability is a crucial factor in determining the management approach, and in this case, the child's blood pressure, although on the lower side, has remained stable after fluid resuscitation 1.
• Conservative management involves close monitoring in an intensive care setting, bed rest, serial hemoglobin measurements, and continued fluid resuscitation as needed, with the child being kept NPO initially and possibly advancing as tolerated.
• Splenectomy (option A) is typically reserved for hemodynamically unstable patients with ongoing bleeding, while splenic artery embolization (option D) might be considered if conservative management fails but before proceeding to surgery 1.
• The guidelines recommend non-operative management (NOM) as the first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma, with the goal of preserving the spleen and minimizing the risk of complications 1.

Management Approach

• The child should be closely monitored in an intensive care setting, with serial clinical and laboratory evaluations to assess the severity of the injury and the effectiveness of the management approach 1.
• The management team should be prepared to intervene promptly if the child's condition deteriorates or if there are signs of ongoing bleeding or other complications 1.
• The use of angiography and angioembolization may be considered if conservative management fails, but this should be done in a center with the capability for precise diagnosis and intensive management of spleen injuries 1.

From the Research

Management of Splenic Injury

The patient in question has a splenic tear of 3cm and a blood pressure of 90/60, which has not improved after administration of 1000ml of fluid IV. The management of such a patient can be considered as follows:

• The patient is hemodynamically unstable, which may require immediate intervention.
• According to the study by 2, splenic angioembolization (SAE) can be used as a first intervention in hypotensive patients with massive splenic injury, without an increased risk of mortality.
• However, the study by 3 suggests that angioembolization and splenectomy have similar survival rates in patients arriving hypotensive with severe, image-confirmed blunt splenic injuries.
• The study by 4 found that SAE was associated with lower odds of in-hospital mortality, shorter ICU length of stay, and lower transfusion requirements compared to splenectomy in hemodynamically stable patients with high-grade blunt splenic injuries.
• The study by 5 highlights the importance of splenic preservation and the role of SAE in non-operative management of splenic trauma.
• The study by 6 provides evidence to support non-operative management of splenic injuries in hemodynamically stable patients, with better outcomes than operative management.

Treatment Options

Considering the patient's condition, the treatment options can be:

• Splenectomy (option A): may be considered in cases where the patient is hemodynamically unstable and other interventions are not feasible.
• Observation and conservative management (option B): may not be suitable for this patient due to their hemodynamic instability.
• Reimplantation (option C): not a standard procedure for splenic injury.
• Splenic artery embolization (option D): can be considered as a viable option for this patient, given the evidence from the studies by 5, 2, and 4.