Death and Complications Conference 10/18/2012 Keri Quinn Trauma Surgery

Complication: ICU transfer, delayed diagnosis 48 yo woman, echo trauma alert s/p MCC at 55mph. The bike was laid down when another vehicle pulled out in front of hers. She was helmeted and had no LOC. EMS placed a traction splint on her RLE open femur fracture. Her chief complaint was severe pain in her right thigh. BP 108/83 HR 82 RR 22 Pox 95% on RA Alert, oriented, moderate distress PERRL, no facial instability NSR, CTAB Abd soft, nontender Spine nontender, no stepoffs RLE open femur fracture 2+ pulses, equal throughout

PMH/PSH: substance abuse, anxiety, C-section SOC: +tob, +EtOH, +cocaine Meds: citalopram Imaging: Severely comminuted open right distal femur fracture L4 transverse process fracture Right mandibular angle fracture Area of hypodensity in medial spleen, possible small splenic laceration

HD#1—ex-fix R femur HD#2—persistent oozing from ex-fix, Hgb 10.1 HD#3—ORIF mandible, Hgb 9.8 HD#4—persistent oozing, refused labs, hemodynamically stable hypotension overnight—SBP 70’s-80’s, transient response to fluid bolus HD#5—SBP 70’s, HR 120’s, lethargic, slight abdominal tenderness, oozing from ex-fix —stat CBC: Hgb 5, started transfusion, transferred to STICU —worsening abdominal exam, RUQ fluid stripe on FAST exam —to OR for ex-lap

Intraop findings: about 800mL blood in abdomen, dark clots in LUQ, torn splenic capsule Pathology: 70% of capsule absent, remaining capsule on hilar surface, areas of hemorrhage and minute lacerations on hilar surface, small subcapsular hematoma

Splenic trauma One of the most commonly injured intra- abdominal organs Fractured ribs and pulmonary contusions most common associated injures Left upper abdomen, chest wall, or left shoulder pain (Kehr’s sign), seatbelt sign, hematoma, contusion Negative history/unremarkable abdominal exam do not reliably exclude splenic injury

Diagnostic evaluation FAST exam  Unstable patient  Negative exam does not exclude splenic injury DPL  >100,000 RBC’s/HPF  High sensitivity CT scan  Stable patient  Hemoperitoneum  Hypodensity  Contrast blush/extravasation

AAST Organ Injury Scale

Initial Management Hemodynamically unstable with positive FAST or DPL  abdominal exploration Peritonitis  abdominal exploration Patient with additional abdominal injuries  abdominal exploration Hemodynamically stable  CT scan, initial management is non-operative  Monitored bed  Serial hgb  Serial abdominal exams  Consider embolization

EAST Guidelines for NOM of blunt injury to spleen Initial non-operative management (NOM) of stable patients Immediate operation or embolization of unstable patients, patients with peritonitis go to OR Age, grade of injury, and amount of hemoperitoneum are not contraindications to NOM. Hemodynamic instability is a contraindication to NOM. CT with IV contrast is the most reliable method to assess severity of spleen injury Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

EAST Guidelines cont’d Angiography with embolization should be considered if  contrast blush is seen on CT  AAST grade > 3  moderate hemoperitoneum is present  evidence of ongoing bleeding Angiography is an adjunct to NOM  patients at high risk for delayed bleed  to look for vascular injuries (pseudoaneurysms) that may lead to rupture or delayed hemorrhage Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

Guidelines cont’d NOM should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and OR is immediately available Clinical status dictates need for followup imaging Contrast blush is not an absolute indication for operation or angio-embolization. Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

Blunt Splenic Injury in Adults: Multi-Institutional study of the Eastern Association for the Surgery of Trauma. Journal of Trauma. 2000;(49): Multi-institutional retrospective study Factors determining successful NOM of blunt splenic trauma in adults 38.5% direct to laparotomy 61.5% admitted for NOM 10.8% failed NOM, required laparotomy  60.9% of failures occur in first 24 hours  Failure rate increased significantly by AAST injury grade

Failure rate for non operative management (adults) Grade 15% Grade 210% Grade 320% Grade 433% Grade 575% Peitzman, A. et al. Blunt Splenic Injury in Adults: Multi-Institutional study of the Eastern Association for the Surgery of Trauma. Journal of Trauma. 2000;(49):

Successful NOM associated with  Higher BP and HCT  Less severe trauma based on Injury Severity Score Glasgow Coma Scale Splenic grade Quantity of hemoperitoneum 54.8% of patients were successfully managed nonoperatively

Learning points Investigate hypotension. Any abdominal trauma, think spleen. Negative history, physical exam, and imaging, still think spleen. Splenic injury in a hemodynamically stable patient may be followed non operatively. Splenic injury of any grade can bleed and patient can die. Don’t let that happen.

Delayed Rupture  75% occur within 2 weeks in several series  Can occur anytime (days, months, years)  Actual incidence of delayed rupture very low  Need to inform patients of this prior to D/C

Nonoperative Management Patient selection  Hemodynamic stability  Patient age  Severity of injury  Other associated injuries Unstable patients suspected of splenic injury and intra-abdominal hemorrhage should undergo exlap and splenectomy

Clinical evaluation  Altered level of consciousness  Decreased UOP  Mottled skin  Hemodynamic instability