Overview
Definition:
Pediatric splenic injury refers to damage to the spleen, a vital organ in the upper left quadrant of the abdomen, typically resulting from blunt abdominal trauma
Nonoperative management (NOM) aims to avoid splenectomy, preserving splenic function.
Epidemiology:
Splenic injuries are the most common intra-abdominal injuries in children following blunt trauma, accounting for approximately 50% of such injuries
They are most frequently caused by falls, bicycle accidents, and motor vehicle collisions
Male children are more commonly affected
Grade of injury dictates management and prognosis.
Clinical Significance:
The spleen plays crucial roles in immune function (antibody production, opsonization) and red blood cell filtration
Splenectomy in children significantly increases the risk of overwhelming post-splenectomy infection (OPSI), a potentially life-threatening complication
Therefore, NOM is the preferred approach whenever feasible to preserve splenic function and reduce long-term morbidity.
Clinical Presentation
Symptoms:
Abdominal pain, often localized to the left upper quadrant or radiating to the left shoulder (Kehr's sign)
Abdominal distension
Nausea and vomiting
Signs of hypovolemic shock in severe cases: pallor, tachycardia, hypotension, altered mental status.
Signs:
Tenderness in the left upper quadrant
Guarding and rebound tenderness
Palpable abdominal mass (less common)
Bruising or ecchymosis over the left flank (flank abrasion sign)
Signs of shock: hypotension, tachycardia, tachypnea
Decreased breath sounds on the left due to diaphragmatic irritation or hemothorax.
Diagnostic Criteria:
No specific diagnostic criteria exist
diagnosis relies on clinical suspicion in a trauma setting and confirmation with imaging
American Association for the Surgery of Trauma (AAST) organ injury scale is used to grade splenic injuries, guiding management decisions.
Diagnostic Approach
History Taking:
Detailed mechanism of injury (blunt trauma, falls, sports, MVC)
Age and weight of the child
Vital signs at presentation
Previous abdominal surgeries or medical conditions
Medications (anticoagulants, NSAIDs).
Physical Examination:
Assess for signs of trauma to the abdomen and chest
Perform a thorough abdominal examination, including inspection for bruising, auscultation for bowel sounds, palpation for tenderness, guarding, and rebound
Evaluate for signs of hypovolemic shock
Assess for associated injuries.
Investigations:
FAST (Focused Assessment with Sonography for Trauma) examination: Initial bedside ultrasound to detect free fluid in the abdomen and pelvis
Computed Tomography (CT) scan of the abdomen and pelvis with intravenous contrast: The gold standard for diagnosing and grading splenic injuries
It identifies lacerations, hematomas, and active extravasation
Laboratory tests: Complete blood count (CBC) to assess for anemia and hemoconcentration
coagulation profile
blood type and crossmatch.
Differential Diagnosis:
Gastric or duodenal perforation
Pancreatic injury
Renal injury
Left lower lobe pneumonia
Mesenteric injury
Diaphragmatic rupture
Rib fractures.
Management
Initial Management:
Resuscitation with intravenous fluids (crystalloids, colloids) and blood products if hemodynamically unstable
Maintain airway, breathing, and circulation (ABCs)
Pain management
Strict bed rest.
Nonoperative Management:
Reserved for hemodynamically stable patients with confirmed splenic injury on imaging
Serial abdominal examinations are crucial to monitor for signs of deterioration
Hemodynamic stability is the key determinant
Grade of injury (AAST Grade I-III often suitable for NOM
Grade IV-V may require intervention)
Absence of active contrast extravasation on CT scan.
Activity Restriction:
Strict bed rest initially
Gradual mobilization as tolerated
Restrictions on contact sports and strenuous physical activity are essential to prevent re-injury and delayed bleeding
Duration of restriction is typically 4-6 weeks for low-grade injuries and longer (up to 3-6 months) for higher grades or those requiring embolization
Clear guidance on return to play is vital.
Supportive Care:
Continuous hemodynamic monitoring
Serial hemoglobin and hematocrit checks
Adequate pain control
Nutritional support as tolerated
Prophylactic antibiotics are not routinely recommended unless there is an associated hollow viscus injury
Pneumococcal and meningococcal vaccinations should be administered if splenectomy becomes necessary.
Complications
Early Complications:
Hemorrhagic shock
Hemoperitoneum
Delayed splenic rupture (days to weeks after initial injury).
Late Complications:
Overwhelming post-splenectomy infection (OPSI) if splenectomy is performed
Pseudocyst formation
Splenomegaly
Chronic pain.
Prevention Strategies:
Adherence to strict activity restriction protocols
Close monitoring for signs of re-bleeding or deterioration
Judicious use of splenectomy, opting for NOM and splenic artery embolization when appropriate.
Prognosis
Factors Affecting Prognosis:
Grade of splenic injury
Hemodynamic stability at presentation
Presence of associated injuries
Timeliness and appropriateness of management
Patient's age and comorbidities.
Outcomes:
Excellent outcomes with successful NOM, with preservation of splenic function and immune competence
Higher grades of injury, especially those requiring embolization or rarely surgery, may have a slightly higher risk of complications
Successful NOM rates in pediatric splenic trauma are high, often exceeding 90%.
Follow Up:
Regular clinical follow-up is necessary to assess for resolution of symptoms and to guide return to normal activities
Serial abdominal examinations are performed during hospitalization
Outpatient follow-up may include imaging if there are concerns
Clear discharge instructions regarding activity limitations and warning signs are critical.
Key Points
Exam Focus:
NOM is preferred for hemodynamically stable pediatric splenic injuries
AAST grading is crucial
Serial abdominal exams are paramount in NOM
Splenectomy significantly increases OPSI risk
Activity restriction duration depends on injury grade.
Clinical Pearls:
Always consider splenic injury in a child with blunt abdominal trauma, even with minimal external signs
Kehr's sign is a classic indicator
FAST exam can quickly identify free fluid
CT scan is definitive for grading and planning management
Embolization is a key NOM adjunct for higher-grade injuries.
Common Mistakes:
Prematurely opting for splenectomy without considering NOM
Inadequate monitoring of hemodynamically stable patients on NOM
Insufficient duration or premature cessation of activity restrictions, leading to re-injury
Failure to vaccinate post-splenectomy patients.