General Surgery · Year 3 · from General Surgery

Case 1: Blunt Abdominal Trauma with Splenic Injury

Patient Demographics

  • Age: 28 years
  • Sex: Male
  • Occupation: Construction worker

Chief Complaint

Patient brought by EMS after motor vehicle collision

History of Present Illness

The patient was the restrained driver of a vehicle that was T-boned on the driver's side at approximately 40 mph. There was significant intrusion into the driver compartment. He was awake at the scene but complained of left-sided chest and abdominal pain. He was placed in a cervical collar and transported to the trauma center. He denies loss of consciousness.

Prehospital Information

  • GCS 15 at scene
  • BP 98/68, HR 118
  • 2 large-bore IVs placed
  • 1L crystalloid infused en route

Primary Survey (ATLS)

  • A (Airway): Patent, speaking in full sentences, no stridor
  • B (Breathing): Bilateral breath sounds, splinting on left, RR 24
  • C (Circulation): BP 94/62, HR 122, pale, cool extremities, cap refill 4 seconds
  • D (Disability): GCS 15, pupils equal and reactive
  • E (Exposure): Left flank contusion, seat belt sign across abdomen

FAST Examination

  • Positive: Free fluid in left upper quadrant (splenorenal recess)
  • Positive: Free fluid in pelvis (pouch of Douglas)
  • No pericardial effusion

Resuscitation

  • Activation of massive transfusion protocol
  • Blood products: 2 units PRBCs, 2 units FFP initiated
  • Tranexamic acid 1g IV
  • Vital signs after resuscitation: BP 102/68, HR 108 (transient responder)

Secondary Survey

  • Head/Neck: C-collar in place, no facial injuries
  • Chest: Left chest wall tenderness, no crepitus, bilateral breath sounds
  • Abdomen: Distended, diffuse tenderness, guarding, seat belt sign
  • Pelvis: Stable to compression
  • Extremities: Left knee contusion, no deformity

Laboratory Results (Initial)

  • Hemoglobin: 10.2 g/dL
  • Lactate: 4.8 mmol/L
  • Base deficit: -6
  • INR: 1.1
  • Platelets: 198,000/μL

Imaging

Chest X-ray:

  • Left lower rib fractures (ribs 9, 10, 11)
  • No pneumothorax
  • No hemothorax

CT Abdomen/Pelvis with IV contrast (patient stabilized):

  • Grade IV splenic laceration with active extravasation (blush)
  • Large hemoperitoneum
  • No hollow viscus injury
  • No renal injury
  • No pelvic fracture

Diagnosis

  • Grade IV splenic laceration with active hemorrhage
  • Left lower rib fractures

Management Decision

Given:

  • Hemodynamic instability (transient responder)
  • High-grade splenic injury with active blush
  • Large hemoperitoneum

Decision: Angioembolization vs. operative management

  • Patient transiently stabilized with resuscitation
  • Interventional radiology immediately available
  • Proceed with splenic artery embolization

Interventional Radiology

  • Main splenic artery coil embolization performed
  • Successful occlusion of bleeding vessel
  • Patient monitored in surgical ICU

Post-Embolization Course

  • Hemoglobin stabilized at 9.8 g/dL (no further transfusions needed)
  • Lactate normalized by 12 hours
  • Serial abdominal exams: Improving
  • DVT prophylaxis initiated at 48 hours

Hospital Course

  • ICU x 3 days
  • Transitioned to floor
  • Ambulating by day 4
  • Discharged day 6

Post-Splenectomy/Splenic Injury Considerations

  • Spleen preserved (non-operative management successful)
  • No OPSI (overwhelming post-splenectomy infection) prophylaxis needed
  • Activity restrictions: No contact sports for 3 months
  • Repeat imaging at 1 week: Stable

Teaching Points

  1. ATLS primary survey is systematic and life-saving
  2. FAST exam rapidly identifies hemoperitoneum
  3. Hemodynamically unstable patients with positive FAST → OR
  4. Transient responders may be candidates for angioembolization
  5. Non-operative management is standard for stable blunt splenic injury
  6. Splenic artery embolization can salvage spleen in selected patients
  7. Grade of injury and hemodynamic status guide management

Clinical Image

Image Description: Focused Assessment with Sonography for Trauma (FAST) examination demonstrating free fluid (anechoic stripe) in the splenorenal recess (left upper quadrant view), indicating hemoperitoneum in the setting of blunt abdominal trauma.

Attribution: Image from Wikimedia Commons, Category:Trauma surgery. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery

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