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Grade 3 Isolated Splenic Laceration with Hemodynamic Instability
Published in Savio George Barreto, Shailesh V. Shrikhande, Dilemmas in Abdominal Surgery, 2020
Maria Grazia Sibilla, Sofia Battisti, Federico Coccolini
The clinical presentation of a patient with splenic rupture includes left upper quadrant pain, Kehr’s sign (shoulder pain secondary to diaphragmatic irritation by the hemoperitoneum), as well as signs of hemodynamic impairment and abdominal tenderness and guard (with signs of peritonism). Hemodynamic instability in adults implies a patient who, at admission, has a systolic blood pressure <90 mmHg and a heart rate of >120 bpm with evidence of skin vasoconstriction (cool, clammy, and decreased capillary refill), altered level of consciousness and/or shortness of breath, or a blood pressure >90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs and/or admission base excess >−5 mmol/L and/or shock index >1 and/or transfusion requirement of at least four to six units of packed red blood cells within the first 24 hours. The approach to decision making in a patient in shock is determined by their response to initial fluid resuscitation according to advanced trauma life support criteria that is, initial fluid bolus with 2,000 mL or 29 mg/kg body weight of Ringer’s lactate in adults or children over 15–20 minutes. Unstable patients can grossly be divided into two main groups: responders and non-responders. A third subgroup exists and is called transient responders. Transient responders initially recover from hypotension, but may experience subsequent deterioration of perfusion indices with the tapering fluid administration to maintenance levels. A non-responder, on the contrary, does not respond to the initial fluid challenge [2].
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
This patient is presenting with a ruptured spleen (left lower rib fractures with associated hypotension) secondary to trauma. Patients present with abdominal pain, left shoulder tip pain (Kehr’s sign), hypotension, and tachycardia. Bruising may present over the left upper abdomen, left chest, or left lower back and is associated with underlying haemorrhage.
Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice
Published in Physiotherapy Theory and Practice, 2023
Carla Sforza, Michele Margelli, Firas Mourad, Fabrizio Brindisino, John D. Heick, Filippo Maselli
Four criteria are described to diagnose non-traumatic splenic rupture: 1) the absence of an unusual trauma or strain that could plausibly injure the spleen; 2) the absence of clear damage in other organs adversely affecting the spleen; 3) the absence of scars that could suggest previous splenic damage; and 4) a normal spleen at both macroscopic and microscopic examination excluding findings of rupture and hemorrhage (Almeida et al., 2016; Fama’ et al., 2015). The typical clinical presentation includes sudden abdominal pain, more intense in the left upper quadrant that often refers to the left shoulder (Kehr’s Sign) associated with abdominal stiffness and hemodynamic instability, defined as perfusion failure, represented by clinical features of circulatory shock and advanced heart failure (Fama’ et al., 2015; Renzulli et al., 2009; Weil, 2005). However, the primary complaints of the patient, in this case, were unique presenting with a more insidious onset localized to the RUQ. Kehr’s sign is the classic example of referred pain by the involvement of the phrenic nerve; this pattern of pain is typically felt above the clavicle on the left (Soyuncu, Bektas, and Cete, 2012). In this case, Kehr’s sign was only evoked during provocation maneuver with Murphy’s test, which is normally performed to investigate the gallbladder and the gastrointestinal system (Murphy, 1903). Less frequently, it is possible to recognize a palpable mass in the splenic region (Balance’s sign) (Wehbe, Raffi, and Osborne, 2008) and associated nonspecific systemic symptoms such as nausea, dizziness and syncope (Aubrey-Bassler and Sowers, 2012). In our case, the patient did not complain of any systemic symptoms.