Management of Shattered Spleen in Children with Penetrating Abdominal Trauma
For children with penetrating abdominal trauma and a shattered spleen, immediate operative management is recommended if the patient is hemodynamically unstable, while hemodynamically stable patients with isolated splenic injury should be transferred to a pediatric trauma center for potential non-operative management. 1, 2
Initial Assessment and Stabilization
Hemodynamic status evaluation: The primary determinant for management approach
- Unstable: Tachycardia, hypotension, poor perfusion, decreased urine output
- Stable: Normal vital signs, responsive to initial fluid resuscitation
Imaging for stable patients:
Management Algorithm
Immediate Operative Management Indications
Operative management is required for children with:
- Persistent hemodynamic instability despite resuscitation
- Transfusion requirement of ≥40 mL/kg of blood products within 24 hours
- Ongoing blood loss
- Evidence of hollow viscus injury, peritonitis, bowel evisceration, or impalement 2
- Completely shattered spleen (grade V injury) with hemodynamic instability 2
Non-Operative Management Considerations
NOM may be attempted in children with:
- Hemodynamic stability
- No evidence of other injuries requiring laparotomy
- Facility with capability for:
Operative Approaches
When surgery is required:
- Attempt splenic preservation whenever possible, especially in children 1, 2
- Splenorrhaphy techniques should be considered for repairable injuries 3
- Partial splenectomy may be appropriate for localized damage
- Total splenectomy as last resort when preservation is not possible due to:
- Severity of splenic destruction
- Hemodynamic instability
- Associated injuries requiring rapid control 2
Post-Management Care
For Non-Operative Management
- 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
- Activity restriction for 2-4 months for moderate to severe injuries 2
- Ultrasound follow-up to monitor healing and detect complications 2
For Operative Management
- Monitor for post-operative bleeding (occurs in 1.6-3% of cases) 2
- Watch for infectious complications (significantly higher in splenectomy at 32% vs 4.8% in NOM) 2
Complications and Prophylaxis
- Post-splenectomy vaccination: Against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) 14 days after splenectomy 2
- Prophylactic antibiotics: Recommended lifelong, especially important in the first two years 2
- Thromboprophylaxis: Initially mechanical methods, followed by LMWH when bleeding risk decreases 2
- Overwhelming post-splenectomy infection (OPSI): A serious potential complication requiring vigilance 2
Special Considerations for Penetrating Trauma
While most literature focuses on blunt trauma management, penetrating splenic trauma presents unique challenges:
- Higher likelihood of requiring operative intervention compared to blunt trauma 1
- Less opportunity for non-operative management due to associated injuries 4
- When isolated and stable, laparoscopic exploration with splenorrhaphy can be considered in select cases 3
Pitfalls to Avoid
- Attempting NOM in unstable patients or inappropriate settings
- Delaying necessary operative intervention when non-operative management is failing
- Performing total splenectomy when partial preservation is possible
- Neglecting post-splenectomy vaccination and antibiotic prophylaxis
- Underestimating the risk of delayed splenic rupture (can occur 4-10 days after trauma) 2
The management approach must balance the risk of hemorrhage against the immunological benefits of splenic preservation, with the ultimate goal of minimizing mortality and preserving quality of life.