the modern spleen

[Timothy Lightfoot]

Just a thought,
but can't pulmonary embolism cause; plueural effusion, 
upper abdominal discomfort (left lower lobe, left upper 
abdo discomfort), reduced SpO2, raised temps >37.8 (though 
40 is prob too high),  etc in an immobile patient, post 
traumatic injury (and embolisation of spleen) and probably 
not on prophylaxis due to injury and bleeding?  just 
wondered what the list thought for my bown education more 
than anything else.

Tim


> Message: 1
> Date: Thu, 7 Jun 2007 06:49:06 -0600
>From: "caesar ursic" <cmursic at gmail.com>
> Subject: Re: the modern spleen
> To: "Trauma &amp, Critical Care mailing list" 
><trauma-list at trauma.org>
> Message-ID:
> 	<7d3839570706070549j791908d4r6ccfc5ae1a89ed0d at mail.gmail.com>
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> 
> 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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