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Thu Jun 7 16:22:37 BST 2007

The angio shows a very definite segmental branch occlusion corresponding to  
the area of non-enhancement. There is going to be an infarctions from the  
trauma. Antibiotics debatable for splenic artery embolization. i have never done  
it with good outcomes. prophylactice antibiotics for midsplenic infarct  
(estimate 20% or so) not based on evidence or experience but not unreasonable. I  
guess we have to consider diaphragmatic injury or pulmonary contusion

In a message dated 6/7/2007 7:50:06 A.M. Eastern Standard Time,  
cmursic at gmail.com writes:

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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