Delayed Rupture of a Normal Appearing Spleen After Trauma: Is Our Knowledge Enough? Two Case Reports

Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality

INTRODUCTION

Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients.

METHODS

This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention.

RESULTS

A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention.

CONCLUSION

The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.

Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management

Delayed bleeding is a major issue in patients with high-grade splenic injuries who receive non-operative management (NOM). While only few studies addressed the clinical manifestations of delayed bleeding in these patients. We reviewed the patients with high-grade splenic injuries presented with delayed bleeding, defined as the need for salvage procedures following NOM. There were 138 patients received NOM in study period. Fourteen of 107 patients in the SAE group and 3 of 31 patients in the non-embolization group had delayed bleeding. Among the 17 delayed bleeding episodes, 6 and 11 patients were salvaged by splenectomy and SAE, respectively. Ten (58.9%, 10/17) patients experienced bleeding episodes in the intensive care unit (ICU), whereas seven (41.1%, 7/17) experienced those in the ward or at home. The clinical manifestations of delayed bleeding were a decline in haemoglobin levels (47.1%, 8/17), hypotension (35.3%, 6/17), tachycardia (47.1%, 8/17), new abdominal pain (29.4%, 5/17), and worsening abdominal pain (17.6%, 3/17). For the bleeding episodes detected in the ICU, a decline in haemoglobin (60%, 6/10) was the main manifestation. New abdominal pain (71.43%, 5/7) was the main presentation when the patients left the ICU. In conclusion, abdominal pain was the main early clinical presentation of delayed bleeding following discharge from the ICU or hospital.

A rare case of delayed splenic rupture following initial negative CT scan imaging: A case report and review of the literature

INTRODUCTION

Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma.

CASE PRESENTATION

A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered.

DISCUSSION

The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma.

CONCLUSION

Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission.

Acetabular Surgery in the Prone Position Resulting in a Life-Threatening Splenic Injury: A Case Report

CASE

The case reported involves a patient who developed an unexplained decrease in hemoglobin after acetabular fracture surgery in the prone position. Repeat abdominal computed tomography was remarkable for a massive subcapsular spleen hematoma secondary to rib fracture impingement, which required splenectomy.

CONCLUSION

The spleen can be injured by a fracture rib during prone positioning for fixation of an acetabular fracture. Prone surgical positioning may cause iatrogenic intra-abdominal organ injury in patients with displaced lower rib fractures. Lateral positioning should be considered for acetabular surgery in patients with rib fractures.

Management of a delayed, post-traumatic rupture of splenic artery pseudoaneurysm in a patient with life threatening co-morbidities: A treatment challenge

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Even high-grade splenic injuries are manageable using interventional radiology with selective splenic artery embolization.

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Patient co-morbidities and other associated injuries affect the outcomes.

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Very morbid patients could be salvaged by judiciously executed ICU care and non-invasive procedure undertaken with informed risks.

Introduction

Splenic artery embolization (SAE) is an accepted intervention for patients with traumatic injury AAST III-IV in hemodynamically stable patients, splenic artery aneurysm and pseudoaneurysm (Brian and Charles, 2012). Unusual circumstances may pose different challenges in individual cases.

Case presentation

A 52-year-old male on anticoagulants for past mitral valve replacement presented to us with history of blunt trauma sustained a month prior, was found to have grade IV splenic injury with delayed pseudo-aneurysmal rupture. In addition, his cardiac evaluation revealed an ejection fraction of 20%. A potential life threatening unstable cardiac status and hemodynamic irregularities accentuated due to the hemoperitoneum was an unusual challenge to deal with. After initial stabilization in ICU, the option of distal embolization of splenic artery was undertaken in a well-planned manner.

Discussion

Unstable cardiac condition, anticoagulant therapy and delayed pseudo aneurysmal bleed led us into undertaking this procedure as a semi-emergency with calculated risks. We discuss this case due to the complexities and dilemmas on various aspects which we faced in his management.

Conclusion

Patient tolerated the procedure well and was discharged on the third day of embolization. Our experience taught us the judicious implementation of a viable and only lifesaving option for an otherwise inoperable patient due to multiple co-morbidities and would strongly recommend this interventional radiological, relatively innocuous procedure for salvaging such patients.