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Splenic injury case

William Bromberg brombwi1 at memorialhealth.com
Sat Dec 27 21:45:07 GMT 2014

So you recommend DPL, laparoscopic exploration or laparotomy in every patient with a seat belt sign?

William J. Bromberg, MD, FACS
Sent from my iPhone

> On Dec 27, 2014, at 16:34, Duchesne, Juan C <jduchesn at tulane.edu> wrote:
> Seat belt syndrome is a real issue here, this combine with a splenic
> injury and shock in blunt trauma needs further attention. If you are a
> minimalist the least I will recommend is a DPL. If you are an aggressive
> minimalist then I will recommend a diagnostic laparoscopic exam.......and
> if you just want to do what is the right answer on the ABS boards you
> extend that DPL incision a little bit more upward until you reach the
> xiphoid and a little bit more downward to reach the pubis ;)
> Key points: Define observation?
> 1.FAST as documented by Nicole in Archives 2002 doest have any role in
> seatbelt syndrome. Title: Abdominal Seatbelt Marks in the ERA of FAST.
> 2. F/U CT scans are inconclusive at best
> 3. Serial PE- this needs to be done by the same examiner and although it
> sounds great.....good luck in finding that person. When to finish this
> serial PE? Once SIRS is identified? Small Bowel devascularization with
> gangrene and perforation might not occur until late (day 5 to day 8)
> 4. Serial labs: WBC might increase due to 1. bowel injury 2.spleen infarct
> 3.sepsis 4. Other missed injuries
> I personally don't like to observe polytrauma patients with too many
> variables in the air
> My 2 cents
> J
>> On 12/27/14 2:44 PM, "Karim Brohi" <karimbrohi at gmail.com> wrote:
>> Miklosh hi
>> Assuming this patient has no on-going fluid requirements then she would be
>> suitable for observation.  There's no active bleed on CT so embolisation
>> would be proximal splenic artery to reduce overall flow.   I think the
>> jury
>> is still out on whether proximal coil embolisation reduces the subsequent
>> splenectomy rate for these injuries although I think the evidence is
>> tending to support it.
>> Given this patient has previous surgery and has lost her short gastrics I
>> would avoid embolisation and just manage her conservatively( - and do a
>> splenectomy if she fails observation).
>> Karim
>> On Sat, Dec 27, 2014 at 8:31 AM, Miklosh Bala <mikloshbala at gmail.com>
>> wrote:
>>> 22 yo female following car crush, on arrival HR 120, BP 90/60,
>>> seatbelt sign and posterior hip dislocation. Following resuscitation
>>> (crystalloids) and hip reduction, CT showed splenic rupture (Grade 4)
>>> -no active contrast extravasation.
>>> BP 100' HP 100. No other injury.
>>> The patient 2 years following Sleeve Gastrectomy.
>>> Do you thing angio is safe for this specific case? Short gastric
>>> arteries are divided - is that come to consideration?
>>> --
>>> Miklosh Bala, MD
>>> Head of Trauma and Acute Care Surgery Unit
>>> Hadassah - Hebrew University Medical Center
>>> Tel: (972) 26778800; Fax: (972) 26449412
>>> Email: mikloshbala at gmail.com
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