The January issue of TraumaMedEd is ready to go! This issue deals exclusively with GU trauma.
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Tip of the hat to John Greenwood, who got the correct answer to this problem case. The CT shows that the patient developed a pseudoaneurysm in the spleen (A) with a fistula to the splenic flexure of the colon (B). This resulted in a sentinel bleed that caused an episode of hematochezia.
Could this have been detected at the initial presentation? No, since the pseudoaneurysm was not seen on the initial CT. There is little support in the literature for serial evaluation by CT, but this may be the one case (in a billion!) where it may have been useful. This should not be enough to change your ordering behavior, though.
How does the pseudoaneurysm result in a fistula to the colon? That’s a good question. Pseudoaneurysms typically grow until they rupture, resulting in troublesome bleeding. My suspicion was that there was also a colon injury at the splenic flexure due to the handlebar injury mechanism which allowed this process to develop. Otherwise it’s hard to envision a pseudoaneurysm burrowing through all layers of a normal colon for no real reason.
What’s the proper treatment? In my mind, only exploration with splenectomy and colon resection/repair is acceptable. Embolization of the spleen may reduce the likelihood of future bleeding, but there is still a potential abscess in the area and it’s very difficult to predict what it will do over time.
Reference: Splenocolic fistula after nonoperative management of splenic rupture. Trauma 15(1):86-90, 2013.
No correct guesses yet, but some good tries! Remember, this was a 16 year old male who crashed a motorcycle and sustained liver and spleen injuries. A month after successful nonoperative management, he presents with a single episode of hematochezia.
Here’s a CT scan taken during the second ED visit:
What’s the problem? Any way to have detected it sooner? What to do now?
Comment or tweet your answers!
A 16 year old male was thrown against the handlebars during a motorcycle crash at about 40 mph. He dusted himself off and went home for a few hours. Unfortunately, he slowly developed some abdominal pain.
He presented to an ED several hours later. He was found to have mild, diffuse abdominal pain, normal vital signs, and a positive abdominal FAST exam. CT scan showed a grade IV spleen injury and a grade II liver injury in the right lobe with no extravasation or pseudoaneurysm noted. He was successfully treated nonoperatively and was sent home.
One month later he returns to the ED complaining of a single episode of hematochezia (approximately 200cc). He has an entirely normal exam and vital signs.
Here are my questions for you:
Please tweet your guesses, or leave comments below. Hints tomorrow and answers on Friday. Good luck!
Patient not treated at Regions Hospital
So what’s the INR of FFP? Or stated another way, what’s the lowest you can correct a patient’s INR using infusions of fresh frozen plasma?
One of the mainstays of correcting coagulopathy, either from hemorrhage or due to medication like warfarin, is transfusion of FFP. Frequently, clinicians will write orders to administer FFP until a certain INR is achieved. What is a reaonable INR?
A “normal” INR is 1.0, plus or minus about 0.2, depending on your laboratory. However, two separate studies have shown that transfusion of FFP will not reliably decrease the INR below about 1.7.
Bottom line: The answer to the question is about 1.6. If any clinician orders FFP transfusions with a goal INR below this, it probably won’t happen. And since transfusions of any product have risks, my “juice to squeeze” ratio of risk vs benefit begins to fail at an INR of 1.6. Below that point, the patient needs a normal temperature and good perfusion to drop their INR further.
References: