Monday, January 21, 2008

Sid Crosby






















14 year old boy slashed in the belly at a hockey game the previous night. Came to ER, sent home. Up all night, can't sleep, severe abdominal pain. Mother brings him back to ER in the morning. He's pale, diaphoretic, HR 95, BP 105/75. CT abdomen/pelvis is done (see above). Obviously, the kid has sustained a major splenic injury with resultant massive hemoperitoneum. Now in the old days, you don't think twice, do not pass go, straight to the OR and whack out the spleen. Nowadays, you have to do a lot of thinking. Non-operative management of splenic trauma has become the standard of care, especially in children. Complications of splenectomy include the entity "overwhelming post-splenectomy sepsis" with an attendant mortality of close to 50%. The spleen actually has a useful immunologic function; helps us to clear the bloodstream of the "encapsulated" bacteria (streptococcus pneumoniae, haemophilus influenzae, etc). People who lose their spleen require lifelong immunizations to lower the risk of acquiring post splenectomy infectious complications. We've found that close to 90% of kids with blunt splenic injury can be managed conservatively without an operation.

So how do you decide when it's time to take a kid to the OR? Three main indications:
1. Hemodynamic instability
2. Diffuse peritonitis
3. Transfusion requirements (greater than 6-8 units of packed red cells over a 24 hour period.

Predictors of conservative failure:
1. Grade of splenic injury
2. Evidence of a vascular "blush" on CT scan


Why did I take this kid? The radiologist called and said he was was worried about a possible concommitant splenic artery transection in the area of the pancreatic tail with a suggestion of pancreatic injury. He also has a belly full of blood and was pretty tender, diffusely. Could I have waited a little while? Given him 4 units of blood and see what happened? Sure. He was hemodynamically stable. Even though he looked like a ghost. I could have tried conservative therapy for a short period of time. But I work in a community hospital. There's no "trauma team" to watch the kid. No chief resident to perform serial exams to make sure he wasn't deteriorating. It was just me. What if he decompensated at 3am? Given the CT report and the way the kid looked, I didn't want to mess around. So I took out his spleen. His belly had several liters of old and fresh blood. The spleen looked like a grenade had gone off inside it. Completely ruptured, with several areas of active bleeding. The pancreas was fine. The case took 15 minutes. He'll probably go home in a couple days. No more slap shots this year, but he should be good for next season.

There is data to suggest that this scenario is quite common; kids who come to a community hospital are more likely to get a splenectomy versus a kid who goes to a free standing pediatric hospital with pediatric trauma teams. And that makes sense. Specialized pediatric trauma units have a full contingent of doctors to watch these kids like hawks. I'm ok with that. I did the right thing, I'm sure. You have to practice safe surgery and the safest course is going to be different depending as much on where you practice as how you do it.

13 comments:

rlbates said...

Are these done open or with laproscope these days? I know the blood obscures, but can it be "flushed" or "suctioned" through the scope so that if all else is okay the larger incision can be avoided? Remember my general surgery days were 20 years ago.

surgery resident said...

What did he and his parents think of your reasoning for your management?

Buckeye Surgeon said...

doc bates-For traumatic splenic injuries, you're usually operating under some duress. You want to get that thing out ASAP. Putting a scope in and trying to evacuate 5 liters of hematoma via a tiny lap suctioner would be pure torture. Not to mention time consuming and risky. The case took 15 minutes open. Any elective splenectomy (for sphereocytosis, leukemias, ITP) ought to be done laparoscopically is possible.

Surg res- They were fine with it.

Gaz said...

Dr. Buckeye:

Just wanted to point out real quick that the name of the file of the CT image may be considered a HIPAA violation (unless it's a joke I don't get).

I really enjoy reading your stories and seeing your images, so don't want anything to slip by that may get you in trouble.

rlbates said...

gaz--Sid Crosby is a famous hockey star (http://en.wikipedia.org/wiki/Sidney_Crosby)

Thanks, Buckeye. I thought that was the case, but was unsure (didn't want to slight anyone who might be "good enough" to do it thru the scope).

Bongi said...

you did the right thing for sure. but you don't need me to tell you that. well done.

Gaz said...

Doctor Bates:

I was actually referring to the original name of the file (it was a LASTNAME_FIRSTNAME.bmp but looks like it was changed). I got the Sid Crosby reference. :)

Buckeye Surgeon said...

good catch Gaz. Saved me HIPAA lawsuit!

rlbates said...

gaz, I missed that. :)

DKV said...

Can the case be made that this patient should have been transferred to a peds trauma center, for the reasons you cite?

Buckeye Surgeon said...

dkv- Interesting point. But I'm sitting there looking at a CT report that suggests a major hilar injury in a kid who's looking pretty pale. His BP was 100/70 in ER and those narrow pulse pressures make me nervous. Some labs that were sent from the OR showed that his hemoglobin had actually dropped to 5.7 during the case. In retrospect, I'm pretty sure the kid needed his spleen out, I don't care if you sent him to Johns Hopkins. The hospital where I work is designated level II trauma. We have all the resources (interventional radiology, neurosurgery) that a level I center has, other than the in-house manpower. If the kid was a little more stable, or the family was adamantly opposed to surgery, then I would have considered transferring. It's a judgment call, in the end, that every community surgeon has to be able to live with.

DKV said...

That point came up during my trauma rotation in residency (huge academic center), about operative versus observational management. The team looked at me funny when I claimed that we had "tons of people" to do serial exams on patients - until I pointed out that some hospitals don't have ANY doctors overnight. It definitely makes a difference in management.

Does your ED use their own ultrasound? FAST would have picked this up, probably the day of initial presentation, without the "ED duration of stay" or ionizing radiation concerns of a CT.

Sid Schwab said...

I'd hope this kid would have been operated anywhere he was. Clearly you did right. And by golly, 15 minutes is as good as I could have done!

I've been known to put a few thin slices of spleen into the omentum of a young person. Anyone still doing that?