Emergency Medicine · Trauma
The facts most likely to be tested
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The spleen is the most commonly injured solid organ in blunt abdominal trauma.
Classic findings are LUQ pain and referred left shoulder pain (Kehr sign) from subphrenic blood irritating the left hemidiaphragm.
In hemodynamically unstable patients the FAST exam rapidly detects free intraperitoneal fluid; CT abdomen/pelvis with IV contrast is the gold standard for stable patients to grade injury.
Hemodynamic instability, peritonitis, or failed nonoperative management mandates emergent exploratory laparotomy with splenectomy.
Hemodynamically stable patients without extravasation undergo nonoperative management with serial exams and hemoglobin monitoring.
A contrast blush on CT (active arterial bleeding) in a stable patient requires angiography with embolization.
Post-splenectomy patients carry lifelong risk of overwhelming post-splenectomy infection (OPSI) and require vaccination against encapsulated organisms.
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A 28-year-old man is brought to the ED after a high-speed motor vehicle collision. He complains of left upper quadrant pain and pain at the tip of his left shoulder. His blood pressure is 88/52 mmHg and heart rate is 122/min despite two liters of crystalloid. A bedside FAST exam demonstrates free fluid in the left upper quadrant and pelvis.
Which of the following is the most appropriate next step in management?
Emergent exploratory laparotomy
A hemodynamically unstable blunt trauma patient with a positive FAST exam and persistent hypotension despite fluids requires emergent laparotomy, not CT imaging. The combination of LUQ pain and Kehr sign points to splenic injury, the most commonly injured solid organ in blunt trauma.
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Etiology / Epidemiology
The most commonly injured solid organ in blunt abdominal trauma.
Clinical Manifestations
Left upper quadrant (LUQ) pain, referred left shoulder pain (Kehr sign), and hemodynamic instability.
Diagnosis
FAST exam for unstable patients; CT abdomen/pelvis with IV contrast is the gold standard for stable patients.
Treatment
Nonoperative management for stable patients; emergent exploratory laparotomy with splenectomy for hemodynamically unstable patients.
Prognosis
Splenectomy carries a lifelong risk of overwhelming post-splenectomy infection (OPSI) requiring vaccination against encapsulated organisms.
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Epidemiology & Etiology
The spleen is the most frequently injured solid organ following blunt abdominal trauma, typically from motor vehicle collisions or falls. There is a significantly increased risk of spontaneous or minor-trauma rupture in patients with splenomegaly, classically seen in infectious mononucleosis (EBV) or malaria.
Pertinent Anatomy
Located in the left upper quadrant and protected by ribs 9-11; left lower rib fractures highly correlate with underlying splenic injury. It is a highly vascular lymphatic organ supplied by the splenic artery (a branch of the celiac trunk) and suspended by the gastrosplenic and splenorenal ligaments.
Pathophysiology
Direct mechanical force or shearing tears the highly vascular splenic parenchyma or its capsule. This disruption causes extravasation of blood into the peritoneal cavity, leading to hemoperitoneum. Progressive intra-abdominal blood loss triggers a sympathetic response, ultimately precipitating hypovolemic shock and cardiovascular collapse if bleeding is unchecked.
Clinical Manifestations
Patients present with LUQ tenderness, guarding, and localized abdominal rigidity. Irritation of the left hemidiaphragm by subphrenic blood causes classic referred left shoulder pain, known as Kehr sign. Progression to hemorrhagic shock manifests with hypotension, tachycardia, pallor, and altered mental status.
Diagnosis
In hemodynamically unstable patients, the FAST exam (Focused Assessment with Sonography for Trauma) is used to rapidly detect free intraperitoneal fluid. In hemodynamically stable patients, CT abdomen/pelvis with IV contrast is the gold standard to grade the laceration (Grades I-V) and identify active arterial bleeding, seen as a contrast blush.
Treatment
Hemodynamically stable patients without active extravasation undergo nonoperative management (NOM) with serial abdominal exams and hemoglobin monitoring. Stable patients with a contrast blush on CT require angiography with embolization. Hemodynamic instability, peritonitis, or failure of NOM mandates emergent exploratory laparotomy for splenectomy or splenorrhaphy.
Prognosis
Survival is excellent with timely intervention, but splenectomy results in a lifelong risk of overwhelming post-splenectomy infection (OPSI). Asplenic patients must receive vaccinations against encapsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis), ideally administered 14 days post-splenectomy.
Differential Diagnosis
1. Liver laceration: Right-sided trauma presenting with RUQ pain and right shoulder pain.
2. Rib fractures (left 9-11): Localized chest wall pain exacerbated by inspiration, lacks hemoperitoneum unless the spleen is concomitantly injured.
3. Renal trauma: Flank pain, ecchymosis, and gross hematuria.
4. Hollow viscus perforation: Severe, diffuse peritonitis with free air under the diaphragm on imaging.