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Fri Nov 23 02:31:32 GMT 2007

 I have a case I would like some opinion on. The patient is a 19 yo who
fell while snowboarding and hit his head and left torso. He had about 15
seconds of unconsciousness. His main complaint was left posterior chest
wall pain. Evaluation at an outlying facility revealed a left 1st rib
fracture, left pulmonary contusion, occult left pneumothorax and a grade
IV splenic laceration without extravasation of pseudoaneurysm. He was
hemodynamically stable with a normal hematocrit. For some reason,
troponin was drawn and revealed mild elevation. He was transferred to us
for further management. We put him in our ICU for observation and
nonoperative management of his splenic injury. We felt that he likely
had a myocardial contusion as well. Subsequent EKG show 2mm ST segment
elevation in the anterior leads. Somehow, the pulmonary/critical care
service became involved (haven't figured out how yet)--but order serial
troponins, serial EKG's and an ECHO. I saw this the next day and made
fun of them to the nurses--asking how they got involved anyway.
Unfortunately, the echo shows normal cardiac function--BUT an apparent
thrombus in the inferior IVC just below its junction with the atrium.
Well this starts the ball rolling---CTA, MRA, cavagram, IVC filter
placement and full anticoagulation. The IVC gram showed a clear thrombus
adherent to the IVC just above the confluence of the hepatic
veins--measuring about 1.5 x 2 cm.  All of this was accomplished over a
24 hour period when I was off. When I got back, I was worried that this
was VOMIT. I would not have even gotten the echo to begin with. But the
IVC gram seemed pretty clear cut when reviewed with the interventional
radiologist.  Fortunately, the kid has done well. NO splenic
complications despite anticoagulation--although I used a conservative
PTT target of 50-60. Repeat duplex ultrasound shows persistent thrombus
that is smaller--now about 1 cm. My plan is to continue his
anticoagulation for the present and repeat the duplex in 3 or 4 days. If
the thrombus has completely resolved, I want to stop his anticoagulation
altogether. Would anyone continue it for 3-6 months empirically? Would
anyone just stop it now? 

Patrick J. Offner MD MPH
Chief, Surgical Critical Care
St Anthony Central Hospital

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