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ED QUICK QUIZ
WHAT IS THE DIAGNOSIS?
BACKGROUND
A father brings his 15-year-old son to the emergency department because of a large bruise over the son's lower left ribs from being struck by a lacrosse ball during an inter–high school game. In addition to complaining of pain in the upper portion of his left abdomen, the patient also has pain in his left shoulder, which movement seems to aggravate. He is ambulatory and in no acute distress. A triage CXR is normal and he is brought to Majors. On examination, the patient has a BP of 125/78 mm Hg, HR 106 bpm, and a RR of 12 breaths per minute. Temp and SaO2 are normal. He has no trouble walking, but he seems to have a lot of pain while positioning himself on the bed. Findings from cardiorespiratory examination are unremarkable. He has diffuse abdominal tenderness that is most pronounced in the left upper quadrant. No rebound or guarding is observed. The patient has no tenderness to palpation over the left shoulder or clavicle, and he has full range of motion in that joint.
QUESTIONS
1. What is the diagnosis?
2. What would be your first and second choice investigations?
ANSWERS & DISCUSSION
1. Diagnosis
Splenic laceration : The injury is directly over
the patient's spleen. The shoulder pain is from irritation of the diaphragm. When an IV line was started in the ED, the patient's BP temporarily decreased to a systolic of about 90 mm Hg. At the time, this change was thought to be due to a vasovagal episode because his blood pressure soon returned to normal.
2. Investigations However, suspicion of a splenic injury
prompted (2a) a Portable Ultrasound (Image
1), which demonstrated a small amount of free fluid in the splenorenal space.
A subsequent (2b ) CT scan confirmed splenic
injury with a grade 2-3 splenic laceration (Images 2). Intraperitoneal blood was present, with a vascular contrast blush medial to the spleen consistent with active intraperitoneal bleeding. In blunt trauma, the abdominal organ most commonly injured is the spleen, closely followed by the liver. Mechanisms of injury include motor vehicle crashes, assault, sports injuries, and bicycle injuries. Even minor trauma can cause splenic rupture in patients with previous splenomegaly due to mononucleosis, malaria, leukemia, or other conditions. The spleen is a highly vascular organ with the potential to contribute to severe blood loss in the setting of trauma. Patients with splenic injuries may present with isolated left upper quadrant pain or diffuse abdominal tenderness. Referred pain to the left shoulder, as observed in this patient, is due to diaphragmatic irritation from subphrenic blood; this is known as the Kehr sign. Severe haemorrhage may cause abdominal distension and frank shock. A presentation delayed by more than 48 hours after trauma may cause additional findings, such as jaundice or left pleural effusion. Patients in haemodynamically unstable condition with signs of intraperitoneal bleeding should receive aggressive fluid resuscitation and/or blood products. These patients should be sent
