What is the management for a completely shattered spleen in children?

Management of Completely Shattered Spleen in Children

In children with a completely shattered spleen (grade V injury), operative management with attempted partial splenic preservation should be pursued if the patient is hemodynamically unstable, has ongoing blood loss, or has other indications for laparotomy. 1, 2

Initial Assessment and Management Algorithm

Hemodynamic Status Evaluation

• Assess hemodynamic stability (systolic BP of 90 mmHg plus twice the child's age in years)
• Monitor heart rate, mental status, peripheral pulses, skin color, urinary output
• Note: Blood pressure and heart rate are poor markers of hemorrhagic shock in pediatric patients with concurrent head injuries 1

Management Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

1. Immediate operative management is indicated for:

   • Persistent hemodynamic instability despite resuscitation
   • Transfusion of 40 mL/kg of blood products within 24h failing to stabilize the patient
   • Ongoing blood loss
   • Evidence of hollow viscus injury, peritonitis, bowel evisceration, or impalement 1, 2

2. Operative Approach:

   • Attempt splenic preservation (partial splenectomy or splenorrhaphy) whenever possible, even in high-grade injuries 1
   • Complete splenectomy only if partial preservation is not feasible
   • Vaccination against encapsulated bacteria should be administered 14 days after splenectomy 2

For Hemodynamically Stable Patients:

1. Non-operative management (NOM) can be considered only if:

   • Patient is in a facility with capability for intensive monitoring
   • Angiography/angioembolization (AG/AE) is available
   • Operating room is immediately accessible
   • Blood products are readily available
   • No evidence of other injuries requiring laparotomy 1, 2

2. Monitoring during NOM:

   • ICU admission with continuous monitoring for at least 24-48 hours
   • Serial hemoglobin/hematocrit checks every 6 hours
   • Strict bed rest for 48-72 hours 2

3. Indications for conversion to operative management:

   • Development of hemodynamic instability
   • Decreasing hemoglobin levels requiring continuous transfusions
   • Evidence of other injuries requiring laparotomy 1

Role of Angiography/Angioembolization (AG/AE)

• AG/AE may be considered in carefully selected patients who are:
  • Hemodynamically stable
  • Showing signs of persistent hemorrhage not amenable to NOM
  • Have excluded extra-splenic sources of bleeding 1
• Most pediatric patients do not require AG/AE, even with contrast extravasation on CT 1
• For patients >15 years old, adult AG/AE protocols should be followed 1
• Consider AG/AE for persistent pseudoaneurysms prior to discharge 1, 2

Follow-up Care

• For moderate to severe injuries managed non-operatively:
  • Ultrasound follow-up to minimize risk of life-threatening hemorrhage 1
  • Activity restriction for at least 6 weeks 1
  • Consider activity restriction for 2-4 months in severe cases 2

Important Considerations and Pitfalls

1. Age-specific considerations:

   • Children have higher success rates with NOM compared to adults
   • Children treated in dedicated pediatric trauma centers have higher rates of successful NOM than those treated in adult centers 1

2. Post-embolization syndrome:

   • Occurs in up to 90% of children undergoing AG/AE
   • Consists of abdominal pain, nausea, ileus, and fever
   • Usually self-limited, resolving in 6-9 days 1

3. Complications to monitor:

   • Delayed splenic rupture (can occur 4-10 days post-injury)
   • Pseudoaneurysm formation
   • Post-splenectomy infection risk (if splenectomy performed)
   • Pleural effusion and pneumonia (9% each after embolization) 1, 2

4. Vaccination after splenectomy:

   • Required against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis)
   • Should be administered 14 days post-splenectomy 2

By following this structured approach to the management of completely shattered spleen in children, clinicians can optimize outcomes while minimizing morbidity and mortality.