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Thu Jun 7 19:00:35 BST 2007

Oh I agree it is unlikely--but I always worry about the worst. Not that
I would change anything--except to have a low threshold to re-CT the
patient. 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
Sent: Thursday, June 07, 2007 9:17 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: the modern spleen

Agree re: effusion and infarction, but given the time frame and kid's
physical exam I think that a missed bowel injury is highly unlikely....

I have no doubt that Ceasar (not time) will tell!

>>> "Offner, Patrick" <PatrickOffner at Centura.Org> 6/7/2007 10:49 AM >>>
Reactive pleural effusions and fever are very common with this scenario.
I would continue to watch very closely. Missed bowel injury has to be in
the back of your mind. In my experience, splenic infarction is unusual
with main splenic artery embo(but have seen several--including
abscess--after distal embo). Don't believe in prophylactic antibiotics
in this situation--no data.

pat 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Thursday, June 07, 2007 6:49 AM
To: Trauma &amp, Critical Care mailing list
Subject: Re: the modern spleen

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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