Trauma for FRCS (Gen Surg)

Children compensate for haemorrhage by tachycardia and intense peripheral vasoconstriction, so systolic pressure is preserved until a large proportion of the blood volume has been lost: ATLS teaches that it may not fall until 30% has gone, and that frank hypotension signifies decompensated shock with loss of around 45%, shortly before bradycardia and arrest. This boy is already in compensated shock. Narrowing of the pulse pressure, weak or absent peripheral pulses, cool mottled limbs with prolonged capillary refill, and oliguria are all earlier consequences of vasoconstriction and reduced organ perfusion, and should trigger blood-product resuscitation and a search for the source. Reference: ATLS Student Course Manual, 10th edition (2018), chapter on trauma in children.

This is a haemodynamically stable blunt splenic injury with a contained vascular lesion (contrast blush or pseudoaneurysm). Stability makes non-operative management appropriate, but a blush is the strongest predictor that observation alone will fail, so angioembolisation is added to raise the splenic salvage rate. Observation alone or simply repeating the CT leaves a lesion with a high risk of delayed rupture untreated. Laparotomy, whether for splenectomy or splenorrhaphy, is reserved for haemodynamic instability, peritonitis or failed non-operative management, and sacrifices or risks a spleen that can usually be saved. Reference: Coccolini F et al., WSES classification and guidelines for splenic trauma, World J Emerg Surg 2017.