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Splenectomy in Pediatric

Trauma Case Presentation


Identity
Name : An Nida Al Adzkia
Age : 14 years old
MR : 12.62.77.93
MOI : patient was a motorcycle rider, fell by
her own, no eye witness
ToAc : 11.00 04/11/2017
ToAd : 13.00 04/11/17 (RSUD Mojokerto),
01.30 05/11/17 (RSUD Dr Soetomo)
DPJP : dr. I. G. B. Adria H., Sp.B, Sp.BA(K)
Primary survey (01.30)
A: Clear, C-spine control
B: RR 24 x/m, symetrical movement (+), no retraction, no bruise,
vesicular sound, no wheezing
C: peripheral perfussion warm, red, dry, CRT < 2 HR 120 bpm
(weak, regular), BP 90/70 mmHg (MAP 76,6). Sign of free fluid
(+), stable pelvic. No active external hemorrhage. Indwelling
catheter already inserted, urine production + 100 cc (2 hours)
D: GCS 456, round isocore pupil 3/3mm, light response +/+, no
lateralization, no battle sign, no bloody otorrhea, no bloody
rhinorrhea, no brills hematoma
E: excoriation at face, deformity at left arm, no bruise on
abdomen, back, or perineum.
DRE: anal sphincter tone(+), bone fragment (-), blood (-).
Clinical condition
RSUD Mojokerto Management

O2 nasal canule 3 lpm


Resuscitation with crystalloid RL 1500ml
and blood 250 ml
Indwelling catheter insertion
Chest X-ray, Pelvic X-ray, Skull X-ray
CBC (Hb: 5,1)
Chest X-Ray (RSUD Mojokerto)

pneumothorax (-), hematothorax (-), increase


bronchovascular pattern, Fr Costae (-), CTR
Pelvic X-Ray (RSUD Mojokerto)
EBV : 65 ml x 38 kg = 2470 ml
EBL :
Crystalloid given @MJK = 1500 ml ~ 500 ml blood
Blood Given @ MJK = 250 ml
Total volume given = 750 ml (30% EBV)
Condition on arrival at RSDS
Tachycardia 120x/min and Hypotension 90/70 mmHg ~
Hypovolemic shock class II ~ on going EBL 750 ml
Problem
Internal bleeding + Hypovolemic Shock
Class II (on going EBL 30%)
Hemorrhagic anemia
Susp. Closed Fracture Humerus S
Action
O2 nasal canule 3 lpm
Resuscitation
Crystalloid 500 ml ~ 160 ml blood
volume
Blood transfussion 250 ml
Volume resuscitation ~ 416 ml
Immobilize left arm
Re-Evaluation (02.00)
A: Clear, C-spine control
B: RR 24 x/m, symetrical movement (+), no retraction, no bruise,
vesicular sound, no wheezing
C: peripheral perfussion warm, red, dry, CRT < 2 HR 110 bpm
(weak, regular), BP 110/70 mmHg (MAP 83,33). Sign of free fluid
(+), stable pelvic. No active external hemorrhage. Indwelling
catheter already inserted, urine production + 100 cc (2 hours)
D: GCS 456, round isocore pupil 3/3mm, light response +/+, no
lateralization, no battle sign, no bloody otorrhea, no bloody
rhinorrhea, no brills hematoma
E: excoriation at face, deformity at left arm, no bruise on
abdomen, back, or perineum.
DRE: anal sphincter tone(+), bone fragment (-), blood (-).
Adjunct to primary survey
Hb 9,1
HCT 15,7
USG FAST ( RSDS) :
free fluid in Morissons pouch (+),
splenorenal (+), cavum Douglas (+),
paravesica (+), bladder full, intact,
catheter baloon (+)
Assessment
Internal Bleeding (respond to
resuscitation)
Hemorrhagic Anemia
Susp. Closed Fracture Humerus S
Secondary survey (02.00)
Patient was a motorcycle rider, found
unconscious near her motorcycle by the local
people. No eye witness that saw the accident.
Patient forgot the accident, and vomit 2x while
in the Mojokerto Hospital.
She was reffered from RSUD Mojokerto
with total resuscitation 1500 ml
crystalloid and 250 ml blood.
No allergy, no medication, no past illness,
last meal 6 hours before injury, no event
surrounding injury.
B1: airway clear, spotaneous breathing, RR 22-24 cpm,
SpO2 99-100%, symmetrical thoracic wall movement,
no retraction, no bruise, vesicular sound, without
additional sound
B2: peripheral perfussion warm, dry, red, CRT < 2,
HR 110-120 bpm, BP 110/70 mmHg (MAP=83.33)
B3: GCS 456, round isokor pupil 3/3mm, light respon
+/+
B4: urine production 100 cc/2 hours
B5: abdomen slight distended, Sign of free fluid (+)
B6: Deformity of left arm, bruise on face, arm, and foot
Adjunct to secondary
survey
05-11-2017

WBC : 13.100 GDA : 104


Hb : 9.2 SGOT : 126
SGPT : 87
PLT : 204.000
Na : 138
PPT : 13.9 K : 4.3
APTT : 35.3 Cl : 92
Alb : 3.70
Foto Radiologis Humerus S
CT-Scan Abdomen
CT-Scan Abdomen
CT - Scan Abdomen:
Spleen Injury Gr V
Left Kidney Injury
Gr V
Free Fluid Collection
pada cavum
abdomen hingga
cavum pelvis
Re-Evaluation (08.00)
A: Clear, C-spine control
B: RR 24 x/m, symetrical movement (+), no retraction, no bruise,
vesicular sound, no wheezing
C: peripheral perfussion warm, red, dry, CRT < 2 HR 124 bpm
(weak, regular), BP 90/70 mmHg (MAP 76,6). Sign of free fluid
(+), stable pelvic. No active external hemorrhage. Indwelling
catheter already inserted, urine production + 100 cc (2 hours)
D: GCS 456, round isocore pupil 3/3mm, light response +/+, no
lateralization, no battle sign, no bloody otorrhea, no bloody
rhinorrhea, no brills hematoma
E: excoriation at face, deformity at left arm, no bruise on
abdomen, back, or perineum.
DRE: anal sphincter tone(+), bone fragment (-), blood (-).
Assessment
Internal Bleeding (Transient Response)
Hemorrhagic Anemia
Ruptur Lien Grade V
Left Kidney Injury Gr V
Closed Fracture Humerus S
Planning
Laparotomy exploration
Splenectomy + autologous splenic
transplantation
Immobilization and fixation of left
humerus with U- Slab
Blood transfusion
Intraoperative finding
Hemorrhagic Peritoneal fluid + 1000cc
with blood clot
Spleen rupture grade V
The other solid and hollow organ intact
Bladder intact
Retroperitoneal hematome zone II left
and right, bulging, non expanding, non
pulsating
Performed :
Splenectomy
Autologous splenic transplantation
Post Op
Management of Spleen Trauma
Solid Organ Injury
Treatment
> 90% of hemodynamically stable pts
successfully managed non-operatively
Mechanisms for Intra-abdominal
Trauma
1. Motor vehicle collisions
2. Automobile vs pedestrian accidents
3. Fall
4. Handlebar injury from bicycle
5. Sports
Frequency of Pediatric Blunt
Abdominal Injuries

Spleen 27%

Kidney 27%

Liver 15%

Pancreas 2%
Splenic Trauma
Diagnosis:
FAST
Focused Abdominal
Sonography for
Trauma
Operator Dependent
15% false-negative
May miss up to 25% of
liver and spleen injuries Fluid in the subphrenic space and
Compared to CT only splenorenal recess can be detected.
63% sensitive for The image shown demonstrates blood
detecting free fluid (arrow) between the spleen (S) and
diaphragm (D).
Splenic Trauma

Diagnosis:
CT with IV contrast
Noninvasive, highly
accurate, easily
identifies and
quantifies extent of
injury, for stable
patient only
A: Hemoperitoneum with a liver
laceration (arrow) and a
shattered spleen is seen.
AAST Splenic Injury Scale

*Advance one grade for multiple injuries, up to grade III


Moore EE, Cogbill TH, Jurkovich GJ, et al
AAST Splenic Injury Scale

17-yo boy injured on an ATV. Grade I injury with subcapsular fluid


occupying less than 10% of spleens surface area.
AAST Splenic Injury Scale

17-yo girl injured in an MVC. Grade II injury with laceration involving


less than 3 cm of parenchymal depth
AAST Splenic Injury Scale

18-yo boy injured playing football. Lacerations involving more than 3 cm


of parenchymal depth radiating from splenic hilum -grade III laceration
AAST Splenic Injury Scale

16-yo boy injured playing hockey. Fractured spleen involving


more than 25%, Grade IV splenic laceration
AAST Splenic Injury Scale

12-yo boy pedestrian struck by MV. Fractured spleen


with hilar devascularization. Grade V injury.
Splenic Trauma
Complications
Pseudoaneurysms
Often asymptomatic and
resolve over time
If treatment required,
angiographic
embolization may be A. Splenic pseudoaneurysm
used (arrowheads) after nonoperative
treatment of blunt splenic injury.
Also occur in liver B. Successful angiographic
trauma embolization The microcatheter
used to deploy the coils is marked
by the arrowheads and the embolic
coils are marked by the arrows.
Splenic Trauma
Complications
Pseudocysts
Rare: 0.44%
May become large and
painful
Tx: laparoscopic
excision and
marsupialization
Splenic Trauma
Immunocompetence
Vaccination practices vary
Splenic Trauma
If splenectomy is indicated
1. Pt requires vaccinations prior to discharge
Streptococcus pneumoniae
Pneumovax 23
Haemophilus influenzae type B
Hib vaccine
Neisseria meningitidis
Quadravalent meningococcal/diphtheria
conjugate
2. Prophylactic antibiotics controversial
Most centers use penicillin
Splenic Trauma

Treatment
1. Nonoperative failure rate 2%
2. Risks for increased nonoperative failure
rate
More than one solid organ injury
Spleen Grade 5
APSA Guidelines
APSA guidelines for hemodynamically stable children with isolated
spleen or liver injury

CT GRADE I II III IV
Days in ICU None None None 1 day
Hospital stay 2 days 3 days 4 days 5 days
Predischarge None None None None
imaging
Postdischarge None None None None
imaging
Activity 3 weeks 4 weeks 5 weeks 6 weeks
restrictions

From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource
utilization in children with isolated spleen or liver injury.

J Pediatr Surg 35:164-169, 2000


References
Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE,
Groner JI, Shiels WE 2nd. Focused abdominal sonography for trauma (FAST) in children with
blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6.
Holcomb GW III, Murphy JP. Ashcrafts Pediatric Surgery. 5th ed. Philadelphia, PA:
Saunders An Imprint of Elsevier, 2010.
Lynn KN, Werder GM, Callaghan RM, Sullivan AN, Jafri ZH, Bloom DA. Pediatric blunt
splenic trauma: a comprehensive review. Pediatr Radiol (2009) 39:904-916.
Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994
revision). J Trauma 38:323-324, 1995
Sabiston DC II, Townsend CM III. Sabiston Textbook of Surgery. 18 th ed. Philadelphia, PA:
Saunders An Imprint of Elsevier, 2007.
Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen
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injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007
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