Teaching Case

A 16-year-old healthy man presented to the emergency department (ED) following a fall from his motorbike. The delayed abdominal imaging was performed when the patient developed diffuse abdominal tenderness. This case highlights the importance of an understanding of the mechanism of injury and early investigations, which can be life-saving.

A 16-year-old driving his motorbike about 30mph, lost control and fell onto his left side. He presented to the emergency department (ED) as a “non-trauma call” complaining of left pectoral and shoulder pains. His haemodynamic parameters were normal. Blood results showed Haemoglobin (Hb) of 11.6 g/dl and White Blood Cells of 24x10 9/l. Chest pelvic radiographs were unremarkable (Fig. 1, 2). Abdominal examination revealed minimally tender epigastrium. However, 6 hours after admission the patient developed diffuse abdominal tenderness and tachycardia of 127/min with Systolic Blood Pressure (SBP) of 130 mmHg. An urgent CT abdomen/pelvis revealed haemoperitoneum with splenic fracture surrounded by large haematoma (Fig. 3, 4). Ongoing haemodynamic instability, acidosis on arterial blood gas, worsening abdominal pain and further Hb drop to 10.4 g/dl prompted an emergency laparotomy and splenectomy (Fig. 5, 6). Overall, the patient made a post operative uneventful recovery.

Almost 90% of the blunt splenic trauma is successfully treated by the nonoperative management [1]. The rationale for the splenic preservation relates to the risk of the overwhelming post splenectomy sepsis, which can be associated with even 50% mortality [1]. Although many algorithms have been devised, like all guidelines, they do not deliver a clear cut off point regarding the definite treatment [2, 5, 6]. However, they are a useful adjunct and can assist the clinician in the decision regarding imaging, nonoperative or operative management in individual cases.
This case illustrates that understanding of the mechanism of injury and early imaging are vital in the safe management of a blunt splenic trauma [5]. Abdominal trauma in young and healthy patients can be extremely challenging, because this group of patients can compensate the haemorrhagic shock with no change in haemodynamic parameters for a considerable time. Substantive evidence shows that even up to 88% of patients arrive to ED with normal SBP and 44% presents with relative bradycardia [3, 4]. “Management of bleeding following major trauma: an updated European guideline” emphasises the use of mechanism of injury, haemodynamic parameters and response to resuscitation in establishing the diagnosis [5]. If the diagnosis remains unclear then, imaging is advised in haemodynamically stable patients to deliver the diagnosis and definite treatment when appropriate (embolisation) [5]. In this scenario, the mechanism of trauma should alert the admitting team and prompt an immediate CT abdomen to exclude visceral damage. One might argue that an Ultrasound Sound scan (US) should be the first line imaging modality. In this clinical context, US certainly represents a sensible approach in haemodynamically normal patient. However, it is important to remember, that a normal US does not exclude an injury [2]. In practice, identification of the free intraabdominal fluid with the use of US, prompts the urgent CT. Once the splenic trauma is confirmed, this allows for the formulation of the clear management plan. The nonoperative management can be safely practiced providing that regular reassessment of the patient’s status takes place. Any signs of haemodynamic instability lead to change of management, including interventional radiology or laparotomy.
This case brings up a valuable educational point, that mechanism of injury delivers crucial information regarding the energy transfer, which can damage the tissues at the significant distance from the site of an initial impact [7]. This knowledge guides the radiologist and clinician regarding the required best image modality.