Pediatric spleen injury

　　Pediatric spleen injury is often seen in abdominal blunt trauma or falls and collisions, mostly indirect vibration injury, and rarely direct force injury. This disease is often part of severe closed injuries such as falls, collisions, or car accidents, so it is possible to overlook spleen rupture while diagnosing severe and obvious injuries such as craniocerebral injury and multiple fractures, or to overlook other organ injuries while diagnosing spleen rupture. The spleen is a solid organ with high capsule tension and fragile texture, making it a fixed organ in the abdomen. However, it also has a certain degree of mobility and is prone to rupture or tear under strong vibration. Normally, the spleen is protected under the left costal rib and is not easy to be injured, but it is still the most susceptible organ in the abdomen to rupture under strong shock. If the spleen is enlarged and has lesions, especially a congested spleen, it is more prone to rupture when exposed under the costal rib. Abdominal contusions and severe falls and collisions, etc., the incidence of spleen rupture is the highest, often coexisting with liver rupture. The spleen that has increased in size due to disease has a higher chance of rupture, which can be caused by neglectful minor injuries and is called 'spontaneous spleen rupture'.

　　Pediatric spleen injury often leads to shock due to massive bleeding. When blood volume deficiency exceeds compensatory function, shock syndrome will occur, with decreased cardiac output. Despite vasoconstriction of peripheral blood vessels, blood pressure still decreases. Decreased tissue perfusion promotes anaerobic metabolism, leading to increased lactic acid and metabolic acidosis. Redistribution of blood flow helps maintain blood supply to the brain and heart. Further vasoconstriction can cause cellular damage, even death.

　　The typical symptoms of simple spleen rupture are that after being struck directly in the upper left abdomen or suffering severe falls and injuries, the child cannot stand up immediately, especially when the left abdomen is curved, and even cannot stand up. The child prefers to lie on the left side, with the waist bending forward, and is afraid to move. Soon, symptoms such as abdominal pain, distension, poor spirits, and refusal to eat appear. In severe cases, there may be pale complexion, cold sweat, restlessness, and other pre-shock symptoms.

　　Palpation of the left upper quadrant has tenderness, percussion produces dullness, and peritoneal puncture results in hemothorax, indicating a basic diagnosis. If the child's condition allows for movement, an ultrasound examination can show the spleen shape and fissure, and can estimate the amount of bleeding and whether there is a hematoma formation, which is an important diagnostic method before necessary surgery. Hematology is basically normal in the early stage, and significant anemia can be seen after a dozen hours.

　　Since splenic rupture is often part of complex injuries such as falls and collisions, it is necessary to conduct a systemic examination for each child, including otolaryngological reactions, neck movement, chest auscultation, limbs and spine, as well as blood and urine routine. At least 6 hours of observation should be made after the injury, and X-ray, CT, MRI, and other examinations may be performed if necessary to ensure safety and achieve a rapid diagnosis. If it is considered that the spleen is naturally ruptured or pathologically large, further diagnosis of the cause of splenic enlargement is needed to facilitate hemostasis and perform radical treatment. Laparoscopy plays a minor role in the diagnosis and treatment of splenic rupture and can only replace laparotomy when the amount of blood in hemothorax is not large, and no abdominal signs progress after observation for 3 days.

　　　For pediatric splenic trauma, the left upper quadrant palpation has tenderness, percussion produces dullness, and peritoneal puncture results in hemothorax, indicating a basic diagnosis. If the child's condition allows for movement, an ultrasound examination can show the spleen shape and fissure, and can estimate the amount of bleeding and whether there is a hematoma formation. The peripheral blood red blood cell count and hemoglobin level progressively decrease. Abdominal ultrasound examination should be performed, and X-ray, CT, MRI, and other examinations may be performed if necessary.

　　For children with splenic trauma, dietary attention should be paid to lightness. For the first few days after surgery, diet should be adjusted according to individual conditions, with liquid and semi-liquid foods as the mainstay, and eating more high-protein foods is beneficial for wound healing. Pay attention to supplementing a variety of vitamins, eating more fresh vegetables and fruits. Children can eat more lean meats, milk, eggs, and other protein-rich foods, but should mainly avoid spicy foods.

　　Because splenic rupture mainly leads to death from hemorrhagic shock, the primary goal of treatment is to rescue or prevent shock and achieve rapid hemostasis. The traditionally recognized fastest and most reliable measure is immediate emergency splenectomy. In recent years, due to the discovery of a high incidence of fulminant infection after pediatric splenectomy, and the observation that many children with splenic rupture can naturally achieve hemostasis, the past conventional splenectomy therapy has been greatly restricted.
　　1. Treatment principles for pediatric splenic rupture
　　1. At the time of consultation, clinical shock (no blood pressure, semi-comatose) was present: rapid blood transfusion and fluid administration of 60ml/kg, blood pressure could not be restored within 20 minutes, and 60ml/kg was immediately repeated. If the blood pressure does not recover or cannot be maintained stable for 2 hours after it rises, blood transfusion should be performed while surgery is conducted, and hemostasis should be achieved immediately.
　　2. Pre-shock stage at the time of consultation: Children with blood pressure, rapid and fine pulse, and restless spirit should be given rapid blood transfusion and fluid infusion of more than 60ml/kg. If the condition does not improve, immediate surgical hemostasis should be performed.
　　3. Normal blood pressure and pulse at the time of consultation: If the blood pressure and pulse are normal at the time of consultation, the child is calm, the blood transfusion and fluid infusion of 60ml/kg is stable, then continue to observe. In case of sudden blood pressure drop, immediate surgery should be performed to explore and stop the bleeding.
　　Second, Observation and Non-surgical Treatment
　　It includes absolute bed rest, fasting and gastrointestinal decompression, administration of sedatives to make the child sleep peacefully, maintaining venous access, intravenous fluid administration to maintain nutrition and administration of hemostatic agents and antibiotics. Blood transfusion should be based on the hemoglobin level, generally maintained at 90-120g/L. After 24 hours, if the child is mentally normal, has a good appetite, the abdominal tenderness is reduced, and there is no distension, he can start with liquid food and then semi-liquid food. The child should strictly rest in bed for 1 week, and can resume diet and activity only after the abdominal signs disappear and the blood count returns to normal. During the observation period, blood pressure should be measured every hour, and hemoglobin should be checked every 6 hours until stable for 48 hours. In case of sudden blood pressure drop, rapid intravenous fluid and blood transfusion of 60ml/kg should be administered immediately. If the stability cannot be restored, immediate surgery should be prepared.
　　Third, Surgical Hemostasis
　　In case of acute massive hemorrhage, rapid splenectomy (grasping incision method) should be performed for抢救休克. Immediately grasp the spleen, clamp the splenic pedicle with a splenic pedicle clamp or a right-angle clamp, suck out the accumulated blood, and then carefully separate the hilum of the spleen. If necessary, ligate the vessels and perform splenectomy. If the rupture is not large and the bleeding is not severe, the spleen membrane should be sutured as much as possible to absorb the hemostatic gelatin sponge, hemostatic gauze, thrombin, and other preparations to prevent hemorrhage.粉碎性脾破裂可用可吸收之脾网(可用白肠线编制)将破脾包拢拉紧加压止血，以止血纱等加强。According to the condition of the rupture, partial splenectomy can also be performed. If the splenic pedicle is ruptured, it can only be removed. However, after splenectomy, the intact part can be cleaned with saline, cut into 20-30 thin slices (1-2cm)×(1-2cm)×(1-2mm) and transplanted into the omentum to retain immune function. It is best to try to retain 1/3 of the spleen tissue. During the operation, the liver, kidney, pancreas, and retroperitoneum should be explored at the same time, and in most cases, hemostasis can be achieved by suturing. The abdominal cavity should be left with a drain.