You are called urgently to the resuscitation room for a trauma call. An 18-year-old girl has fallen from her horse. During her descent the horse kicked her, and she is now complaining of generalized abdominal pain and left shoulder-tip pain.
She is talking and examination of her chest is normal. The oxygen saturations are 100 per cent on 24 per cent oxygen. Initially, her pulse rate is 110/min with a blood pressure of 84/60 mmHg. She is slightly drowsy and her Glasgow Coma Score (GCS) is 14. On examination of the abdomen, there is an abrasion on the left side beneath the costal margin
with tenderness in the left upper quadrant. There is no evidence of any other injuries and the urinalysis is clear. The patient is given 2 L of intravenous fluids and the blood pressure improves to 130/90 mmHg. As the patient has now become stable, a computerized tomography scan (CT) of the chest and abdomen is obtained.
• What does the CT show?
• Are there any alternative investigations to CT?
• What special requirements may this patient have postoperatively?
The patient has sustained a tear to the splenic capsule causing intraperitoneal bleeding. The CT shows the fractured spleen with surrounding haematoma. The shoulder-tip pain described is known as Kehr’s sign, and is indicative of blood in the peritoneal cavity causing diaphragmatic irritation. Unstable patients suspected of splenic injury and intra-abdominal haemorrhage should undergo exploratory laparotomy and splenic repair or removal. Blunt trauma, with evidence of haemodynamic instability which is unresponsive to fluid challenge, should be considered to be a life-threatening solid organ (splenic) injury. Those patients who respond to an initial fluid bolus, only to deteriorate again with a drop in blood pressure and increasing tachycardia, are also likely to have a solid organ injury with ongoing haemorrhage. Transfer to the CT scanner can be extremely dangerous for an unstable patient.
Focused abdominal sonographic technique (FAST) is helpful in diagnosing the presence or absence of blood in the peritoneal cavity. Diagnostic peritoneal lavage may be a valuable adjunct if time permits and multiple other injuries are present. In a haemodynamically stable trauma patient, CT scanning provides an ideal non-invasive method for evaluating the
spleen. The decision for operative intervention is determined by the grade of the injury and the patient’s current or pre-existing medical conditions. If possible, it is preferable to repair minor tears of the spleen. Those patients who undergo splenectomy have a lifetime risk of septicaemia and should receive immunizations against pneumococcus, haemophilus
• Whenever possible the spleen should be conserved.
• Patients require lifelong prophylactic antibiotics after splenectomy.