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Sun Jun 10 15:12:01 BST 2007

Well, I suppose a pulm embolus is possible, but he has been on prophylaxis
since admission (calf pneumatic compressors) and has been ambulating
frequently as of late....

I wasn't aware that splenic artery embolization was a risk factor for pulm
embolism....

BTW, I re-scanned him last night and the spleen looks the same as it did
originally - i.e. no new areas of non-perfusion, no abvious intrasplenic
fluid collections, no other signs of badness....

Today he's feeling much better, abdomen much less tender, Hb is stable, and
fever curve is resolving.  I think we may have gotten away with this one,
this time.  That's the Modern Spleen for ya'!!

C Ursic
Santa Fe
USA

On 6/10/07, Timothy Lightfoot <timlightfoot at doctors.org.uk> wrote:
>
> Just a thought,
> but can't pulmonary embolism cause; plueural effusion,
> upper abdominal discomfort (left lower lobe, left upper
> abdo discomfort), reduced SpO2, raised temps >37.8 (though
> 40 is prob too high),  etc in an immobile patient, post
> traumatic injury (and embolisation of spleen) and probably
> not on prophylaxis due to injury and bleeding?  just
> wondered what the list thought for my bown education more
> than anything else.
>
> Tim
>
>
> > Message: 1
> > Date: Thu, 7 Jun 2007 06:49:06 -0600
> >From: "caesar ursic" <cmursic at gmail.com>
> > Subject: Re: the modern spleen
> > To: "Trauma &amp, Critical Care mailing list"
> ><trauma-list at trauma.org>
> > Message-ID:
> >       <7d3839570706070549j791908d4r6ccfc5ae1a89ed0d at mail.gmail.com>
> > Content-Type: text/plain; charset=ISO-8859-1;
> >format=flowed
> >
> > 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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