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Arab Board Surgery Clinical study materials
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Blunt abdominal trauma with splenic injury and a falling haemoglobin

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Blunt abdominal trauma with splenic injury and a falling haemoglobin

A 24-year-old man is brought in after a high-speed motorcycle crash. He is alert, GCS 15, BP 108/70 mmHg, HR 124/min, RR 26, SpO2 96% on 4 L. He has left upper quadrant and left chest tenderness; breath sounds are reduced on the left. FAST shows free fluid in the left upper quadrant and pelvis. CT (after 1 L crystalloid) shows a grade IV splenic laceration with active contrast extravasation, a left-sided rib fracture with a small pneumothorax, no pneumoperitoneum, and a normal aorta. Hb 92 g/L, lactate 4.2 mmol/L, base deficit −6. He has had 2 L crystalloid and 1 unit of red cells. There is no hybrid angio suite; interventional radiology is available on call within 40 minutes. The operating theatre is free.

1. Is he a candidate for non-operative management? Justify your answer with reference to his physiology and CT findings, and state what you would do in the next 30 minutes.

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Physiology

  • HR 124, lactate 4.2, base deficit −6, and a modest response to 1 unit of blood indicate ongoing haemorrhage and a transient responder at best. He is not yet in decompensated shock but is on the trajectory.
  • A grade IV splenic injury with active contrast extravasation has a high failure rate for non-operative management (up to 20–40% even in stable patients).

Decision

  • Non-operative management is reasonable only in a haemodynamically stable patient with no peritonitis and no ongoing transfusion requirement. He does not meet this: he is tachycardic with a base deficit and has already required blood.
  • The presence of a pneumothorax does not mandate laparotomy; place a chest drain if it is significant and he is symptomatic.

Next 30 minutes

  • Activate massive transfusion protocol (balanced 1:1:1), give tranexamic acid 1 g within 3 h of injury, warm the patient, and correct calcium.
  • Call IR immediately - angioembolisation is the preferred adjunct if he can be stabilised and taken within the window; it is faster and less morbid than splenectomy and preserves splenic function.
  • If he remains tachycardic despite 2 units of blood or becomes unstable, proceed to laparotomy and splenectomy - do not delay for IR in an unstable patient.
  • Send crossmatch, group and save, and repeat Hb/lactate.

Key principle

  • The decision is driven by response to resuscitation, not by CT grade alone. A transient responder with active extravasation should be treated aggressively and early.

2. He undergoes successful angioembolisation. Twelve hours later he develops left shoulder tip pain, fever 38.6 °C, and increasing abdominal pain. What is your differential, and how do you investigate and manage it?

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Differential

  • Splenic infarction/necrosis after embolisation - common and usually managed conservatively; may cause fever and pain.
  • Splenic abscess - rare but serious; suspect if fever persists, especially with a large infarct or gas on imaging.
  • Delayed splenic rupture/re-bleeding - check Hb and repeat FAST/CT.
  • Post-traumatic pancreatitis or pancreatic fistula - left upper quadrant pain and fever.
  • Atelectasis/pneumonia from rib fracture and pneumothorax - check chest.
  • Diaphragmatic injury - consider if there was a left lower chest injury; a missed diaphragm tear can present late.
  • DVT/PE - shoulder tip pain is not typical but consider if immobile.

Investigation

  • Repeat FBC, CRP, lipase, blood cultures, and Hb.
  • CT abdomen with IV contrast (portal venous phase) to assess splenic perfusion, infarct size, abscess, and diaphragm.
  • Chest X-ray/CT for pneumonia and pneumothorax.

Management

  • Splenic infarct without abscess: analgesia, IV antibiotics if febrile, monitor; most resolve. Do not rush to splenectomy.
  • Splenic abscess: percutaneous drainage if accessible, broad-spectrum antibiotics, and splenectomy if drainage fails or the patient is septic.
  • Re-bleeding: back to IR or theatre.
  • Diaphragm injury: repair (laparoscopic or open).

Vaccination

  • If splenectomy becomes necessary, give pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines (preferably 2 weeks before, or post-op) and lifelong prophylactic penicillin if appropriate.