Updated: 12/21/2019

Splenic Laceration / Rupture

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Snapshot
  • A 33-year-old man is brought to a trauma center after a motor vehicle accident. He reports a lot of pain in his chest and his abdomen. Physical exam shows multiple rib fractures on the left side. His vitals show that he is hypotensive even after several liters of crystalloid fluids. A FAST exam shows free fluid in the perisplenic space. He is taken urgently into the operating room for an exploratory laparotomy.
Introduction
  • Overview
    • splenic injury can result from trauma or nontraumatic causes
      • treatment is usually surgical in a hemodynamically unstable patient
  • Epidemiology
    • risk factors
      • diseases causing splenomegaly
        • infectious mononucleosis
        • dengue fever
        • leukemia/lymphoma
        • malaria
        • malignancies
      • penetrating trauma
      • blunt trauma
      • left-sided rib fracture
  • Pathogenesis
    • functions of the spleen
      • helps fight infection by producing antibodies and other key immune mediators
      • recycles old red blood cells
      • stores platelets and white blood cells
Presentation
  • History
    • trauma
  • Symptoms
    • common symptoms
      • location
        • left upper quadrant pain
        • left shoulder pain (Kehr sign)
        • diffuse abdominal pain
  • Physical exam
    • inspection
      • abdominal bruising
      • tachycardia
      • hypotension
      • shock
    • provocative tests
      • peritoneal signs
        • guarding
        • rigidity
Imaging
  • Abdominal ultrasound
    • FAST exam
      • focused abdominal sonography for trauma
    • indications
      • at bedside for all patients
    • findings
      • intra-abdominal free fluid
  • CT of abdomen
    • indications
      • hemodynamically stable patients with history of blunt abdominal trauma
      • to rule out splenic injury
    • findings
      • splenic bleeding
      • splenic injury
      • pseudoaneurysm
Studies
  • Serum labs
    • may have anemia
    • may have leukocytosis
Differential
  • Splenic abscess
    • key distinguishing factor
      • often in immunocompromised patients and IV drug users
      • fever, leukocytosis, and left upper quadrant pain
Treatment
  • Medical
    • close monitoring and serial abdominal exams
      • indications
        • hemodynamically stable patients
  • Surgical
    • exploratory laparotomy with possible splenectomy
      • indications
        • hemodynamically unstable
        • complete rupture
    • endovascular embolization
      • indications
        • hemodynamically stable
        • incomplete rupture
Complications
  • Infection
  • Acute respiratory distress syndrome
  • Pancreatitis
 

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(M2.GI.15.59) A 26-year-old man with no significant past medical history presents to the ED following a motor vehicle accident. Vital signs on presentation are T 99.0 F, BP 100/60 mmHg, HR 125 bpm, RR 16/min, SpO2 98% on room air. He complains of extreme abdominal pain worse in the left upper quadrant which has worsened over the past 30 minutes. Exam demonstrates abdominal wall rigidity, involuntary guarding, and tenderness on light percussion. Bedside sonography shows evidence for hemoperitoneum. Despite administering more intravenous fluids, repeat vitals are T 98.9 F, BP 82/50 mm hg, HR 180 bpm, RR 20/min, SpO2 97% on room air. Which of the following is the best next step? Tested Concept

QID: 106394
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Normal saline bolus and re-evaluation of hemodynamics after infusion

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(0/18)

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CT abdomen and pelvis

6%

(1/18)

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Morphine

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Abdominal plain film

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5

Exploratory laparotomy

89%

(16/18)

L 3 D

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