the modern spleen

Offner, Patrick PatrickOffner at Centura.Org
Fri Jun 8 15:46:56 BST 2007 

I actually would disagree that CT would be useless. I have seen the
situation you describe with delayed necrosis-with small bowel thickening
and free air. A followup CT at 4-5 days can very well show signs of
bowel injury. I guess I should apologize for evening bringing up the
possibility of a bowel injury. I didn't think this kid had one for all
the reasons noted. I just tend to always keep the idea of missed injury
in the back of my mind in patients with abdominal trauma being managed
nonoperatively. 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
Sent: Friday, June 08, 2007 4:49 AM
To: Critical Care mailing list Trauma &amp
Subject: Re: the modern spleen

Ceasar,

I think you might have gathered that I didn't think this kid had an
enteric injury - too far out and looking too good.  The only point I was
trying to make was that a CT would be useless, and that you are going to
either DPL or open.  Fact is that a mesenteric rent or a bowel wall
contusion could actually lead to bowel wall necrosis and delayed
presentation that could be diagnosed with a DPL.  Again, this kid is
eating, and by your description has a perfectly benign abdominal exam 5
days out, so I do not think that bowel injury is a consideration.

OBTW - how long after his vaccines did he start spiking fevers?

Ron

>>> "caesar ursic" <cmursic at gmail.com> 6/7/2007 4:15 PM >>>
*Ron, I agree with you that a missed intestinal injury is possible and
should not be approached cavalierly, but this kid is now eating, has a
soft, flat belly with bowel sounds (still tender over the left upper
quadrant, but not guarding) and just 'looks' to darn good for that.*

*As for DPL... at five days post injury and with a known hemoperitoneum,
what criteria (other than food particles, a very high amylase, or succus
entericus) would one accept as a 'positive' lavage in this patient?
Surely not an elevated WBC?  *



On 6/7/07, Ronald Gross <Rgross at harthosp.org> wrote:
>
> I hear you - and I too believe that Murphy lives in my back pocket.  I

> have to tell you, however, that if I thought that a bowel injury was 
> probable and not a remote possibility you would have to either DPL the

> kid or take him to the OR.
>
> INCOMING!!!
>
> >>> "Offner, Patrick" <PatrickOffner at Centura.Org> 6/7/2007 2:00 PM >>>
> Oh I agree it is unlikely--but I always worry about the worst. Not 
> that I would change anything--except to have a low threshold to re-CT 
> the patient.
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
> Sent: Thursday, June 07, 2007 9:17 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: the modern spleen
>
> Agree re: effusion and infarction, but given the time frame and kid's 
> physical exam I think that a missed bowel injury is highly
unlikely....
>
> I have no doubt that Ceasar (not time) will tell!
>
> >>> "Offner, Patrick" <PatrickOffner at Centura.Org> 6/7/2007 10:49 AM 
> >>> >>>
> Reactive pleural effusions and fever are very common with this
scenario.
> I would continue to watch very closely. Missed bowel injury has to be 
> in the back of your mind. In my experience, splenic infarction is 
> unusual with main splenic artery embo(but have seen several--including

> abscess--after distal embo). Don't believe in prophylactic antibiotics

> in this situation--no data.
>
> pat
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
> Sent: Thursday, June 07, 2007 6:49 AM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: the modern spleen
>
> ok, I was thinking as were all of you.  There was a large albeit 
> subtle 'blush' on the lateral edge of the injured spleen prior to 
> embolization, so we were thinking that the whole 'raw' edge of the 
> broken spleen was still oozing. The radiologists coiled the main 
> splenic artery, as there were no obvious segmental arterial branches 
> that we could attribute as the main
> supply to the bleeding area.   He inserted about five coils.  Patient
> remain
> hemodynamically normal throughout the whole ordeal.
>
> it is now three hours after presentation to ER, nearly 24 hours since 
> the injury.
>
> Admitted to ICU with Foley catheter; NPO;  I did immunize him with 
> pneumovax at that point (I'm a pessimist by nature).  Serial Hb 
> ordered every six hours initially, then less frequently.  Here's the 
> Hb trend (in g/dL):
>
> admission: 13.9;  six hours: 11.9,  twelve hours: 11.3  eighteen
hours:
> 10.5 twenty-four hours: 9.5; thirty hours: 9.1  thirty eight hours: 
> 9.3; forty eight hours: 9.1;  morning of day five: 9.2  His BP and 
> heart rate remain normal all the time.  His urine output always at or 
> above 0.5cc/kg/hr.
>
> abdominal exam: slowly improving (slower than I would like):  he's 
> quits asking for narcotics by day two; starts passing flatus again by 
> day three (I move him out if ICU at that point); hungry again by day 
> four, starts to eat.
>
> other fun stuff:  his oxygen saturations are slowly dropping on room 
> air.  A chest x ray on day four shows a significant (maybe one-third) 
> left pleural effusion.  The admission CXR was stone-cold normal, and 
> CT cuts (on
> admission) through the lower thorax showed no fluid/consolidation 
> whatsoever.  Reactive pleural effusion?  Drain it or let it be and 
> wait for
> it to reabsorb?   He is now requiring 4 L/min by nasal cannula to
> maintain
> spO2 of 93%.  Not really dyspneic, but not really moving around much 
> either.  Elevation at my hospital in Santa Fe is 7,000 feet (2,100 
> meters).
>
> Oh, and now he's spiking temps to 40 C.  WBC count remains slightly 
> elevated at 14,000 (down from 17,000 on admission).  Urinalysis is 
> clean.  No IV site infections. The angiographer had originally 
> insisted that we give him prophylactic antibiotics prior to the 
> embolization (for one week) to 'cover'
> for splenic infarction and splenic abscess formation.  I didn't.  
> Should I have?  Should I start antibiotics now?  Blood cultures are
pending.
>
> Patient knows he won't be playing football this fall (I told him so) 
> but wants to play basketball starting January.
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