Title: A Case of Delayed Splenic Hemorrhage Following Blunt Abdominal Trauma
Author(s): Trent Perkins, DO; Joseph Noga, DO
Email: Tperkins1@mercy.com
Introduction: Splenic injury is a significant cause of morbidity and mortality following blunt abdominal injury. A majority of the time, this injury is immediately present upon arrival in the emergency department with routine trauma imaging and can be adequately managed and treated. On rare occasions, however, splenic injury is not immediate following trauma and instead occurs hours or even days after the trauma itself. These cases are associated with a significantly higher mortality rate than standard splenic ruptures, likely secondary to delayed time to treatment. Because of this, it is important for those caring for the patient presenting after blunt abdominal trauma to consider the possibility of delayed splenic hemorrhage occurring days after the original injury even if immediate workup is reassuring.
Case Report(s): A 67-year-old female presented to St. Elizabeth Boardman following a fall at home. For two days leading up to the fall, patient had been having copious diarrhea secondary to a recent COVID-19 infection diagnosed by home test a day before. She states she was walking and fell forward to the floor in her kitchen. She arrived hypotensive with a blood pressure of 80/51. Pressures increased to 93/56 after fluid administration. Patient’s physical exam was largely unremarkable with no abdominal tenderness, distension, rigidity, or guarding. CT abdomen and pelvis with IV contrast revealed no acute intrathoracic abnormality. CBC showed stable hemoglobin of 11.5. Patient was evaluated in the hospital during admission for her hypotension and discharged four days later to skilled-nursing facility in stable condition with stable vital signs, with a BP of 142/86. Patient then presented back to the emergency department approximately 8 hours later with severe abdominal pain and syncope. Her initial vital signs on presentation were significant for BP of 68/25 and a heart rate of 154. Abdomen was distended. During this ED visit, CT abdomen and pelvis was repeated and was significant for a 4.9 x 3.9 x 16.1 cm heterogenous fluid collection in the LUQ consistent with inferior splenic pole laceration and associated hemorrhage. Ultimately, the patient expired from her injuries while in the emergency department.
Discussion: Delayed splenic hemorrhage is a rare, often missed, and critical complication of blunt abdominal trauma. CT scan is the preferred imaging modality of the trauma patient and multiple scans are often performed on a patient presenting after a fall or a trauma. Oftentimes, when initial imaging is negative, patient is cleared from the acute traumatic injury perspective and no more studies are performed. There are times when repeat imaging is warranted however. When a patient has a traumatic injury with negative initial imaging, it is important to consider repeat imaging with serial laboratory studies, especially if the patient remains hypotensive despite adequate resuscitation. With repeat examinations on these borderline patients, these often missed cases of delayed splenic injury could be identified and managed , resulting in a decrease in the almost 15% mortality of delayed splenic injury. Overall, a patient with hypotension, tachycardia, and worsening abdominal pain or distension following a recent blunt trauma is suspicious for a splenic injury, regardless of what initial imaging revealed.
