the modern spleen

[caesar ursic]

Ron (Gross):  look at the second cut on the CT.  Ron (Simon): one cut above
and two cuts below cut 2 shows the same interesting high-density blotch
within the substance of the injury.  Radiologist and I look at it for about
five minutes in a darkened room, and we both agree that it must represent
contrast extravasation.  How weird, I think, since this kid looks so good 18
hours out of his injury.  It pays to be 15 years old, I suppose....

here's the angio (one image tells the story):
http://trauma.homestead.com/spleen_angio.html

now what?



On 6/6/07, Ronald Gross <Rgross at harthosp.org> wrote:
>
> Ceasar,
>
> This kid plays the same kind of non-contact football as the "no-hitting"
> hockey I was palying a couple of years ago when I had 3 ribs broken by a
> "non-hit" closing on the net. (PS - I did score!)
>
> Anyway, if NO cuts reveal any contrast extrav, and the kid remains stable,
> I would keep him in house for a couple/three days, then home for a few days
> more (total of 1 week on no activity after discharge).  Embolize if any
> extrav of IV contrast is seen, however.
>
> I know that there is no science to this, but I WOULD repeat a CT at 3-4
> months before I would let him back to either "non-contact contact" or real
> contact sports!
>
> Just my 2 cents.  What did you do?
>
> Best wishes,
> Ron
>
>
>
> >>> "caesar ursic" <cmursic at gmail.com> 6/6/2007 9:57 PM >>>
> Actual current case of mine:
>
> 15 yo male 'accidentally' tackled during spring football training (it was
> supposed to be a 'no-contact' practice session, but...oh well.. )  He said
> the blow 'knocked the wind out of me and hurt pretty bad."  He went home
> that afternoon feeling a bit 'weak' and tried to eat but could not.  Slept
> poorly due to pain in left upper abdomen/lower chest.  Next morning in
> more
> pain, so mom takes him to our ER.  He tells me his left upped belly hurts.
> He's not hungry even though he skipped dinner and breakfast.
>
> His vital signs on arrival:  BP 136/81   HR: 90   RR: 16   TEMP: 36.5
>
> Exam: He looks pretty good, albeit worried.
> Skin: warm, well perfused,  No scleral icterus
> Lungs: Equal breath sounds.
> Chest: minimal tenderness over left lower anterior ribs
> Heart: Normal heart tones.
> Abdomen:  non-distended, no bruises,  bowel sounds present and normal.
> Tender in LUQ with some voluntary guarding; other areas of abdomen are
> NON-tender and soft.
> Back and spine are normal.
> Genitourinary exam: normal
> Rectal exam: normal
>
> Hb: 13.9 g/dL (prior to any intravenous fluids).  WBC 17,000.  Serum
> amylase
> and lipase are normal.  T. Bili: 2.1.  ALT and AST: normal
>
> urinalysis: grossly clear (i.e. no gross hematuria), microscopy shows 5-10
> RBCs per high-power-field.
>
> CT scan of abdomen:  selected cuts
> here<http://trauma.homestead.com/spleen_ct.html>(
> http://trauma.homestead.com/spleen_ct.html). Remainder of abdominal CT
> shows
> NO pneumoperitoneum, NO liver/kidney/pancreatic injury, NO oral contrast
> extravasation, NO periduodenal fluid or thickened loops of
> intestine.  there
> is some fluid in the pelvis and around the lower liver.
>
> Remember, this injury is now approx 18 hours old.  His BP on repeated
> determinations remains normal, and he is NOT tachycardic.
>
> How would you manage this patient?  Next step(s)??
>
> C. Ursic, MD
> Santa Fe
> USA
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Did gyre and gimble in the wabe:
All mimsy were the borogoves,
And the mome raths outgrabe.