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Mon Jan 23 13:05:04 GMT 2012

I would suggest not to over-think this one.  Take to OR when patient is hemodynamically stable, take out the spleen and fix the diaphragm.  The low risk of overwhelming sepsis from splenectomy in a 17 years old boy, should be weighed against the more immediate risk of bleeding which may result in hypotension and a bad neurologic outcome.  Also, there could be a risk that there is still an unrecognized intestinal injury.  I have never performed diaphragmatic repair with an injured spleen still in situ, but my guess is that it might be quite a delicate maneuvre (depending on how severely the spleen in injured) and might result in significant intra-operative blood loss.

Sanjay Gupta

________________________________
 From: Scott Bricker <scottbricker at verizon.net>
To: Trauma-List \[TRAUMA.ORG\] <trauma-list at trauma.org> 
Sent: Monday, January 23, 2012 7:52 AM
Subject: Re: Question on delaying closure of diaphragmatic rupture

What grade was the splenic injury, and what was the severity of the TBI?

Scott Bricker, MD
Harbor-UCLA

Connected by DROID on Verizon Wireless

-----Original message-----
From: Harry Naber <nabercal at wxs.nl>
To: trauma-list at trauma.org
Sent: Mon, Jan 23, 2012 12:43:27 GMT+00:00
Subject: Question on delaying closure of diaphragmatic rupture

Your opinions please.
A 17 yr old boy got involved in a MVA with his moped. He sustained a number of left sided injuries: cerebral contusions (minor), left hemopneumothorax, spleen and left kidney fracture, pelvic fracture(left) and left tibial fracture. Since he was hemodynamically stable and the pelvic fracture did not need fixation only the tibial fracture was taken care of with external fixation after placement of a left thoracic drain. he was kept on the ventilator until the next day because of a slightly lowered GCS before surgery (due to contused brain (?)). He renained hemodynamically stable and his hemoglobin level was stable also without the need for transfusion. Ventilator settings were quite low with and oxygen fraction of 25% for paO2's of 14 kPa.
On the second day his thoracic X ray revealed a diafragmatic rupture with intrathoracic gastric air configuration; no free air etc.
What to do? An abdominal approach will lead to further bleeding of the spleen with risk of hemodynamical instability (risk for brain) and possible spleen removal or proceed to immediate repair to prevent complications of the rupture (no signs present, low CRP levels, no problems to ventilate). Maybe delayed repair after 3-4 days will allow spleen salvage without to much extra risk of complications. (PS we lost 2 young adults this year who had been vaccinated properly after traumatc spleen removal a few years earlier due to encapsulated bacterial sepsis). So what are your ideas?
Harry Naber, anesthesiologist -intensivist in a large dutch trauma centre.
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Question on delaying closure of diaphragmatic rupture