Delayed Traumatic Splenic Injury

• Published in: The American journal of emergency medicine Vol. 35; no. 2; pp. 375.e3 - 375.e4
• Main Authors: Nanavati, Pooja, MD, Parker, Brian, MD, MS, Winters, Michael E., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2017; Elsevier Limited
• Subjects: Abdomen; Cysts; Delayed Diagnosis; Emergency; Emergency medical care; Emergency medical services; Hematoma - complications; Hematoma - diagnostic imaging; Hematoma - pathology; Humans; Laparotomy; Male; Middle Aged; Mortality; Spleen; Spleen - diagnostic imaging; Spleen - injuries; Spleen - pathology; Spleen - surgery; Splenectomy; Splenic Diseases - diagnosis; Splenic Diseases - diagnostic imaging; Splenic Diseases - etiology; Splenic Diseases - surgery; Time Factors; Tomography, X-Ray Computed; Trauma centers; Treatment Outcome; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - diagnostic imaging; Wounds, Nonpenetrating - pathology; United States > US
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2016.08.003

Abstract Delayed splenic injury has been well described and typically makes itself known within 2 weeks after a traumatic event. The mortality rate for patients with delayed splenic injury can be as high as 18%. In this report, we describe the course of a 52-year-old man who was brought to our emergency department more than 6 weeks after an acute traumatic injury and was found to have a high-grade splenic injury requiring emergent laparotomy and splenectomy. Emergency care providers should be aware that clinical evidence of splenic injury could be delayed beyond the 2-week period commonly cited in the current literature. Since delayed splenic injury was first reported in 1943 Zabinski and Harkins (1943) [1] , numerous case reports/series have been published about it. Almost all patients with delayed splenic injury in the current literature presented within 2 weeks after acute trauma. Descriptions of the emergence of symptoms beyond 2 weeks are rare Resteghini et al. (2014) [2] . Regardless of the timing, the mortality rate runs as high as 18% Costa et al. (2010) [3] . Emergency care practitioners should consider delayed splenic injury in patients who present beyond the 2-week post-injury period. We describe a man who was injured in a snowboarding incident 6 weeks before his emergency department (ED) presentation. A 52-year-old man with history of hypertension was transported to the ED following a near-syncopal event. During a meeting, he had become lightheaded, diaphoretic, and pale, so his co-workers called 9–1-1. Upon arrival, he was still diaphoretic and pale but not distressed. Vital signs were as follows: blood pressure, 103/74 mm Hg; heart rate, 102 beats/min; respiratory rate, 16 breaths/min; and pulse oximetry reading, 100%, breathing room air. He was afebrile and his glucose level was normal. He described lightheadedness and lower left-sided chest pain. Six weeks earlier, he had fallen while snowboarding and suspected left-sided rib fractures but never sought medical evaluation. The pain had diminished during the weeks preceding his current presentation. The remainder of his systems review was unremarkable. Physical examination was normal, except tenderness in his left lower lateral chest. His abdomen revealed no ecchymosis, distension, rebound, or guarding. The patient was a smoker and had a family history of premature coronary artery disease in first-degree relatives. Given his age, risk factors, and presentation, the initial evaluation focused on excluding a cardiac cause of his symptoms. Electrocardiography showed normal rhythms, so a chest radiograph was requested. While it was being obtained, the patient had a syncopal event. He was brought back to the ED, where his blood pressure was recorded as 88/49 mm Hg. The left lower chest discomfort had increased and now extended into his abdomen. Repeat physical examination demonstrated abdominal tenderness to palpation in the left upper quadrant and periumbilical regions. Bedside ultrasound (US) examination revealed fluid in Morrison's pouch (Fig. 1). He underwent emergent computed tomography (CT) of the abdomen, which revealed hemoperitoneum, grade IV splenic injury, and multiple pseudoaneurysms within the spleen. Complete blood count demonstrated a hemoglobin of 12.2 g/dL. He underwent splenectomy and removal of 800 ml of blood. Splenic injury diagnosed 48 hours after the traumatic event is considered a “delayed” presentation Resteghini et al. (2014) [2] . The cause of delayed presentation remains unclear. Several theories have been proposed. The most common is that the splenic capsule tears at the time of injury, resulting in a perisplenic hematoma, Kodikara and Sivasubramanium (2009) [4] which is initially contained by the surrounding organs but continues to enlarge and eventually ruptures. A second theory postulates that a subcapsular hematoma forms after the traumatic event Riezzo et al. (2014) [5] and continues to expand, increasing tension within the splenic capsule. Rupture ensues, filling the intraperitoneal cavity with blood. The splenic artery or vein can also be injured, resulting in pseudoaneurysms or splenic pseudocysts Weinberg et al. (2010) [6] . Increasing size, irritation, and pressure from such vascular abnormalities can cause delayed clinical symptoms Weinberg et al. (2010) [6]. Based on existing reports, the timing of delayed injury is accepted as 1 to 2 weeks after the traumatic event. The clinical presentation depends on the severity of injury. Some patients experience mild abdominal pain and have normal vital signs; others are critically ill with hypotension and tachycardia. Kehr's sign (left shoulder pain with palpation of the left upper quadrant) or Balance's sign (a tender palpable mass in the left upper quadrant) can be elicited on physical examination. Diagnostic imaging is needed to confirm the injury. Twenty-eight percent of patients who sustain multiple rib fractures have liver or splenic injury Al-Hassani et al. (2010) [7] . Other radiographic findings (rarely seen) include elevated left hemidiaphragm, left lower lobe atelectasis, and left pleural effusion. Bedside US can detect intraabdominal free fluid in patients in whom splenic injury is suspected and should be performed urgently in any unstable patient. Importantly, US misses up to 29% of intraabdominal injuries identified by CT Chiu et al. (1997) [8] . Because of the limitations of plain films and US, CT of the abdomen with intravenous contrast is recommended for diagnosing delayed splenic injury. Once a splenic injury is identified, the consulting surgical service should be notified. Depending on the degree and type of injury, several treatment options are available, including splenectomy and, in less severe cases, interventional radiology. Our patient presented 6 weeks after the initial trauma, well beyond the time frame cited in the literature. We postulate that a subcapsular hematoma formed in response to his initial injury and then, weeks later, ruptured. Once splenic injury was diagnosed, the patient recalled a recent period of physical exertion, which could have disrupted a clot or caused the capsule to rupture.