Injuries of the spleen

Splenic injury after blunt abdominal trauma: an unusual presentation

BACKGROUND

The spleen is the most commonly injured viscus in blunt abdominal trauma. Abdominal pain with left upper quadrant tenderness or signs of peritonitis in a patient with history of trauma is the most common presentation of this condition.

OBJECTIVE

To describe an unusual presentation of splenic rupture in a patient with history of motor vehicle crash and blunt abdominal trauma.

CASE REPORT

A young man was brought to the Emergency Department with a history of being in a motor vehicle crash 10 h earlier. He experienced gradually worsening difficulty breathing while sitting or lying down for the previous 4 h, although he was asymptomatic in the upright position. He was transported to the hospital standing upright, supported by two men, on the open back of a vehicle normally used to transport cattle. The patient was found to have left upper quadrant abdominal tenderness on examination and free fluid in the pelvis on the focused abdominal sonography for trauma examination done while the patient was standing. A grade III splenic injury with hemoperitoneum was diagnosed on computed tomography scan and the patient was treated with splenectomy.

CONCLUSION

We report an unusual presentation of a splenic injury in a young man who had symptoms only in the supine position.

Postsplenectomy type-1 hypersensitivity response: a correlation between IL-4 and IgE serum levels

Authors demonstrated the presence of allergic manifestations in splenectomized patients following traumatic rupture of this organ. In particular, allergic diathesis, as supported by serum IgE increase, was exclusively found in patients with preserved T helper (h)-2 lymphocyte function. Th-2 function was monitored by measuring serum levels of interleukin (IL)-4, a cytokine involved in IgE synthesis. On the opposite, in splenectomized individuals with a reduced Th-2 function as supported by lower IL-4 serum levels, no IgE increase and allergic manifestations were detectable. On these grounds, authors hypothesize that allergic manifestations may be correlated to splenectomy since its exeresis may favor the persistence of antigens in the blood. Consequentially, in patients with a preserved Th-2 function, antigenic overload may lead to IgE increase and allergy onset.

Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma

OBJECTIVE

To determine the accuracy of physical examination and ultrasonographic evaluation performed by emergency physicians in cases of blunt abdominal trauma for the early diagnosis of intraabdominal haemorrhage.

METHODS

In this clinical prospective study, trauma patients were evaluated with four-quadrant ultrasonography by emergency physicians after initial stabilisation and physical examination. Diagnoses based on demographic data, physical examination and emergency physician's ultrasonography were compared with the subsequent clinical course.

RESULTS

A total of 442 patients participated in the study. The sensitivity and specificity of emergency physician's ultrasonographic examination to detect intraabdominal haemorrhage were 86 and 99%, respectively. Pre-test sensitivity and specificity of physical examination to detect intraabdominal haemorrhage were 39 and 90%, respectively.

CONCLUSIONS

Physical examination was not a reliable method to detect intraabdominal haemorrhage in cases of blunt abdominal trauma. In contrast, abdominal ultrasonography performed by emergency physicians was a reliable diagnostic tool. Emergency physicians should be familiar with abdominal ultrasonographic examination, which should be routine in cases of blunt abdominal trauma.

Unsuspected internal organ traumatic injuries

Emergency medicine physicians can avoid missed traumatic intra-abdominal injury by adopting a paradigm for patient evaluation that recognizes the patterns of injury associated with pathology, the importance of positive and negative physical findings, and the limitations of diagnostic studies. The burden of avoiding missed traumatic injuries does not rest with emergency medicine physicians alone, however. A missed diagnosis may be the result of a medical error involving multiple systems and individuals.Ultimately, decreasing the incidence of missed traumatic injury is an opportunity for quality improvement for all practitioners involved in the care of patients with trauma.

Hepatic trauma: contemporary management

In the introduction, I posed several questions that were issues/controversies. The answers will probably be interpreted as equally controversial. I do not believe there is strong evidence that the incidence of liver injuries has increased. Diagnostic modalities have contributed to this seeming increase, as well as population increases and the concentration of severe liver injuries in trauma centers, now present in 35 states. I believe there are more blunt injuries now, relative to penetrating injuries. The peak of penetrating injuries occurred in the 1970s and 1980s and lasted almost 2 decades. I believe some authors are overly enthusiastic for nonoperative management. I am particularly critical of authors who do not include all components of the surgical armamentarium into their treatment of severe liver injuries. I also believe that the complications following nonoperative management are currently unacceptable, as documented in the references. I have shared with you the strategies for operative management, but there are equally good or better strategies in the surgical literature.

Not so FAST

BACKGROUND

Focused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients.

METHODS

From October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance.

RESULTS

Patients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; chi analysis showed significant discordance between FAST examination and CT scan (5.85%, < 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries.

CONCLUSION

Use of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.

Tratamento não-operatório do trauma hepático

O fígado é o órgão mais comumente lesado nos traumatismos abdominais; no entanto, com freqüência a laparotomia revela ausência de sangramento ativo, limitando-se a intervenção à limpeza e drenagem da cavidade. Em função deste aspecto e do fato de que a maioria das lesões hepáticas é de menor gravidade, surgiu a opção do tratamento não-operatório. Esta conduta representa hoje a terapêutica de escolha nas lesões hepáticas em doentes conscientes e estáveis do ponto de vista circulatório. A experiência mostra que é um método seguro, efetivo e com excelentes resultados. Neste artigo, os autores fazem uma revisão e análise crítica do assunto, discutindo os critérios de seleção dos doentes, a avaliação e os riscos e complicações do tratamento não-operatório do trauma hepático.

Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma

BACKGROUND

Evaluating blunt abdominal trauma remains a resource intensive aspect of trauma care. Recently, emergency department ultrasound has been promulgated as a noninvasive diagnostic alternative. Consequently, we hypothesized that an ultrasound based key clinical pathway (KCP) would reduce the number of diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scans required to evaluate blunt abdominal trauma without increased risk to the patient.

METHODS

This study was a prospective analysis of patients evaluated for blunt abdominal trauma during a 3-month period using this KCP compared with a 3-month historical cohort.

RESULTS

Data were collected for 486 KCP patients and were compared with 516 patients in the study cohort. No differences were noted regarding demographics, number of laparotomies, or type of injuries. Using the KCP, DPL was reduced from 17 to 4%, and computed tomography from 56 to 26%. Furthermore, the injury severity score increased from 11.6 to 21.5 for DPL patients and from 4.6 to 8.3 for computed tomography patients. Ultrasound exams were used exclusively in 65% of patients.

CONCLUSIONS

An ultrasound based KCP resulted in significant reductions in the use of invasive DPL and costly CT scanning in the evaluation of blunt abdominal trauma without risk to the patient.

CT of abdominal and pelvic trauma

CT is the diagnostic study of choice at most institutions in the evaluation of hemodynamically stable, blunt abdominal trauma. It is highly specific and sensitive in the detection and definition of the extent of most intra-abdominal and pelvic injuries. The clinical examination is the most important factor in the decision regarding whether surgery should be undertaken. However, a progressive and steady trend toward the nonoperative management of solid parenchymal injury is occurring, partly because of the ability of CT to define the extent of injury and to follow its healing over time. Clinical management, CT findings, and the utility of these findings are presented and discussed for each organ system injury within the abdomen and pelvis.

Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid

The minimum volume of intraperitoneal fluid that is detectable in Morison's pouch with ultrasound in the trauma setting is not well defined. To evaluate this question, we used diagnostic peritoneal lavage (DPL) as a model for intraperitoneal hemorrhage and undertook a blinded prospective study of the sensitivity of ultrasound in detecting intraperitoneal fluid. Participants included attending physicians and residents in emergency medicine, radiology, and surgery. During the infusion of the DPL fluid, participants continuously scanned Morison's pouch until they detected fluid. All participants were blinded to the rate of infusion and the volume infused. One hundred patients were entered into the study. The mean volume of fluid detected was 619 mL. Only 10% of participants detected fluid volumes less than 400 mL and the overall sensitivity at one liter was 97%. We conclude that reliable detection of intraperitoneal fluid in Morison's pouch requires a greater volume than has been previously described.

Current concepts in splenic trauma

Despite its protected location inside the rib cage, the spleen remains the most commonly injured organ after blunt abdominal trauma. The clinical decision-making process of splenic injury management continues to evolve due to improvements in surgical technique and noninvasive assessment. Splenic preservation techniques and splenic injury grading systems using computerized tomography were developed due to an increased understanding of the spleen's importance in the body's immunological defense system and awareness of the spleen's resiliency after injury. The concept of splenic salvage using splenorrhaphy and nonoperative management was initially applied to the pediatric population during the 1970s, with great success. Application of splenic salvage to hemodynamically stable adult patients with known or unknown splenic injury has demonstrated that adults can be less predictable in their clinical course. Despite the rigorous attention splenic trauma has received, it remains a controversial subject in the surgical and the radiological literature.

Nonoperative management of abdominal trauma

In an effort to reduce the rate of nontherapeutic celiotomy yet avoid the possibility of missed injuries, surgeons are evaluating protocols for nonoperative management of abdominal trauma. Discussion of this controversial issue includes specific approaches to the diagnosis and management of splenic injury, gunshot wounds, and stab wounds.

Management of splenic injuries

The structure and function of the spleen are reviewed in the context of providing a rational basis for splenic salvage after trauma. Guidelines for operative and nonoperative management are provided, and the results of treatment from recent large series are summarized.

Delayed rupture of the spleen

The concept of delayed splenic rupture is an evolving one. The cases reviewed have led us to reserve the term "delayed splenic rupture" for the situation in which early post-traumatic imaging of the spleen is normal and is followed by the diagnosis of splenic hemorrhage 48 or more hours after the initial insult. Post-traumatic splenic evaluation is indicated when the mechanism of injury is likely to injure the spleen, there is unexplained hypovolemia, or the patient complains of left upper quadrant pain or tenderness. Peritoneal lavage is indicated when hypovolemia is the main manifestation. Radionuclide study is used for screening isolated splenic or hepatic injury when the suspicion is low. Reduced availability of visceral angiogram has resulted in CT scan becoming the main diagnostic modality. When a patient presents with blunt abdominal trauma, awareness of the problem of splenic rupture and active diagnostic approach may help reduce the morbidity and mortality associated with splenic hemorrhage, either immediate or delayed.

Torso trauma

This monograph represents an overview of torso trauma. The torso should be viewed as a single unit and injuries may affect the thoracic and abdominal viscera. My approach to the various injuries is pragmatic and usually fairly aggressive. The purpose is to reduce complications and missed injuries and it applies equally well to the surgeon whose practice is extensive or to the surgeon who treats only occasional injuries.

Splenic, pancreatic, and hepatic injuries

The preoperative resuscitation and operative management of hepatic trauma has vastly improved over the past 50 years. The majority of patients can be handled with simple techniques, with close attention to local hemostasis and adequate drainage. When major liver trauma does occur, exsanguination remains the leading cause of death. An integrated effort of physicians, nurses, and ancillary hospital support staff is needed to care for these severely injured patients.

Jejunal perforation occurring in contact sports

Two cases of jejunal rupture following blunt trauma, occurring in participants of contact sports, have been reported. Additionally, a possible mechanism of injury is described.

Intrathoracic rupture of the spleen

The case is reported of a 15-year-old girl who presented following trauma and was found to have a massive congenital diaphragmatic hernia through the foramen of Bochdalek. The spleen, which was intrathoracic, had ruptured. No other similar cases have been reported in the literature hitherto.

Reappraisal of the left lateral decubitus X-ray in splenic rupture

The lateral decubitus view of the barium-filled stomach has been reassessed in a series of 42 patients with possible splenic rupture and compared with a group of 17 patients with splenomegaly. Displacement of the gastric fundus of more than 4 cm from the inner rib margin is highly suggestive of splenic rupture. Where doubt exists, the test should be repeated within a short while. Peritoneal lavage and a full blood count investigation both add to the diagnostic accuracy.