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Splenic injury case

Duchesne, Juan C jduchesn at tulane.edu
Sat Dec 27 22:44:11 GMT 2014


William- read carefully what I stated. Multiple variables : spleen, fluid in abdomen, questionable bowel or mesenteric injury due to presence of seat belt. That's my point. To answer your question : NOT in isolated seat belts signs
J

Juan Duchesne
Trauma Medical Director
GME Medical Director
North Oaks Health System
Hammond LA
Associate Professor of Surgery
Tulane New Orleans LA
LSUHSC New Orleans LA



On Dec 27, 2014, at 15:45, William Bromberg <brombwi1 at memorialhealth.com<mailto:brombwi1 at memorialhealth.com>> wrote:

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<mailto: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<mailto: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<mailto: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<mailto:mikloshbala at gmail.com>
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