SPLEEN RUPTURE EC

ABDOMINAL BLUNT
TRAUMA
GRANDY TALANILA
PATIENT IDENTITY

• Name:Mr S 18 years old

• Age:18 yo
• Date of admission: 28/03/2019
ANAMNESIS

• Patient came to ER post traffic accident 30 minutes before admission, patient

was riding a motorcycle and hit pickup truck from behind, fell of motorcycle
and his left flank hit the road, no nausea and vomiting.
PRIMARY SURVEY

• Airway and cervical spine control: patent, cervical spine intact

• Breathing: 20x/minutes spo2: 99%
• Circulation: 120/80 mmhg, hr 78
• Disability: gcs 15
• Exposure: open wound (-)
SECONDARY SURVEY

• Physical examination :
• General appearances : CM
• Head : ca-/-, si-/-, pupil isokor 3mm/3mm,
• Cor : reguler, murmur-, gallop-
• Pulmo : Rh-/-, Wh-/-, vesiculer.
• Abdomen : pain -, peristaltic +, spleen schuffner 5 fast USG (-) pain on upper left quadrant.
• Ext : warm, CRT<2 sec.
ASSESMENT

• Mild head trauma gcs 15

• Blunt trauma region abdomen
PLANNING

• Mefenamic acid, cefadroxyl, KIE

• Observe patient on ER
4 HOURS LATER

• S: patient vomit twice on ER, headache, abdominal pain

• O: BP: 70/40 HR: 115 rr:23 spo2: 98%
• General appearances : CM
• Head : ca-/-, si-/-, pupil isokor 3mm/3mm,
• Cor : reguler, murmur-, gallop-
• Pulmo : Rh-/-, Wh-/-, vesiculer.
• Abdomen : pain +, peristaltic reduced, pain on upperleft quadrant, fast usg (+)
• Ext : Cold, CRT<2 sec.
4 HOURS LATER

• A: generalized peritonitis ec intraabdominal bleeding

• P: administer NGT, DC
• Report to specialist: planned to laparotomy cito.
LAB FINDINGS

• Hb: 10,0
• 4hours later hb: 7.5
• After operation: 5.7
INTRA OP FINDINGS

• Dx: intraabdominal bleeding ec spleen

rupture grade 5,
SUMMARY

28/3/2019: laparotomy cito,

therapy: meropenem,
ranitidine, piracetam,
phenytoin, kalnex, NGT, DC,
fluid balance 7/4/2019: patient discharged

4/4/2019: smooth diet, aff

drain and DC, move to
observation ward
CLASSIFICATION OF ABDOMINAL TRAUMA

• Blunt trauma
• Penetrating trauma
• Iatrogenic trauma
MECHANISM OF INJURY

• Crushing injury, solid organ more vulnerable

• (Deceleration injuries: differential movements of fixed and
non-fixed structures (e.g. liver and spleen laceration at sites
of supporting ligaments)
• External compression(seat belt syndrome), whether from
direct blows or from external compression against a fixed
object (e.g., lap belt, spinal column),it causes sudden rise in
intra abdominal pressure and culminate in hollow viscous
organ injury.
ABDOMINAL TRAUMA

• The main consequences of abdominal trauma are

haemorrhage and sepsis.
• The energy transfer during deceleration and compression
tears solid organs and bowel mesentery resulting in
intraperitoneal bleeding.
• Sepsis is the most common cause of death occurring more
than 48 hours after injury.
BLUNT ABDOMINAL TRAUMA
• Blunt abdominal injuries may be initially
• Blunt abdominal trauma is a leading cause of
morbidity and mortality among all age
groups. Identification of serious intra-
abdominal pathology is often challenging;
many injuries may not manifest during the
initial assessment and treatment period
difficult to detect if the patient has no signs of
external trauma and alteration to their vital
signs. Significant blood loss can occur without
any dramatic change in appearance of the
abdomen. A direct blow from blunt trauma can
lead to solid organ rupture and visceral
damage causing haemorrhage, contamination
with the visceral contents, peritonitis and
associated pelvic injuries.

https://trauma.reach.vic.gov.au/guidelines/abdominal-trauma/introduction
 • The most common organs injured are the
spleen, liver and small bowel.

https://emedicine.medscape.com/article/1980980-overview
SPLEEN

• Normal spleen size varies between 9-11cm

• Placed under costae IX-XI
• Wheighs around 90-150 gr.
VASCULARIZATION
• Artery, vena splenica
• Artery vena gastrica brevis
• Artery vena gastroepiploica
PRIMARY SURVEY
A. Airway with cervical spine protection
• Assess for airway stability
• Assess for soiled airway
• Attempt simple airway maneuvers if required
• Secure the airway if necessary (treat airway obstruction
as a medical emergency) consider intubation if level of
consciousness <9
B. Breathing and ventilation
• Assess the chest
• Record the oxygen saturation (SpO2
C. Circulation with haemorrhage
control
• Assess circulation and perfusion
• Commence fluid resuscitation as indicated
• Perform a FAST scan

D. Disability: Neurological status

SPLEEN RUPTURE GRADING
BASED ON AMERICAN
ASSOSCIATION SURGERY OF
TRAUMA

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5562999/
Case courtesy of Dr Sachintha Hapugoda, Radiopaedia.org, rID: 51434
CLINICAL PRESENTATION

• Kehr’s sign – Clot collected under left

diaphragm irritates it and the phrenic nerve(
C3, C4) causing referred pain in left shoulder
15 minutes after foot end elevation
• because the supraclavicular nerves have the
same cervical nerves origin as the phrenic
nerve, C3 and C4
 DIAGNOSTIC
APPROACH FOR
ABDOMINAL
BLUNT TRAUMA

Townsend, sabiston textbook of surgery 20th edition. elsevier

DIAGNOSTIC
Fast usg

Diagnostic peritoneal
lavage
• 10 cc of Gross
blood?
• 100,000 RBC/mm3
• Intestinal Contents
INDICATION OF EMERGENCY LAPAROTOMY

• Haemodynamic instability systolic BP< 90mHg with a positive FAST.

• Evidence of peritonitis (tenderness on palpation, involuntary guarding and percussion tenderness).
• Traumatic diaphragmatic injury with herniation.
• Severe solid organ injury (e.g. kidney and spleen).
• Infarction due to post traumatic occlusion of the blood supply.
• Mesenteric tear/s.
• Unexplained moderate to large amounts of intraperitoneal free fluid (200-≥500mls).
• Failed non-operative management.

https://trauma.reach.vic.gov.au/guidelines/abdominal-trauma/primary-survey
SPLENECTOMY

https://www.doereport.com/generateexhibit.php?ID=73253&E
xhibitKeywordsRaw=&TL=&A=
COMPLICATIONS

• Early
1. Acute gastric dilatation (could increase intra abdominal pressure)
2. Fundal ischemia- hematemesis, perforation
3. Reactionary hemorrhage from splenic vessel
• Late
1. Infection; pneumococcal, viral, OPSI (overwhelming post splenectomy infection)
OPSI

• Splenectomized patients are a

significant infection risk, because the
spleen is the largest accumulation of
lymphoid tissue in the body
• The pathogenesis and risk of developing
fatal OPSI remain ill-defined, however,
especially in the normal adult host.
• The mortality rate is 50%-70% despite
aggressive therapy.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675110/
REFERENCE

1. https://trauma.reach.vic.gov.au/guidelines/abdominal-trauma/introduction
2. https://emedicine.medscape.com/article/1980980-overview
3. Wilkes, G. (2014). Abdominal Trauma. In C. P, J. G, K. AM, M. Little, & B. A, Textbook of Adult Emergency
Medicine, 3rd edition (pp. 99-103). Sydney: Elsevier.
4. Diercks, D. C. (2016, 12 18). Initial evaluation and management of blunt abdominal trauma in adults.
Retrieved from Up to date: http://www.uptodate.com/contents/initial-evaluation-and-management-of-
blunt-abdominal-trauma-in-adults
5. Townsend, sabiston textbook of surgery 20th edition. Elsevier
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675110/