On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Stem
A 28-year-old male is brought to the emergency department after a motorcycle accident. He was the unrestrained rider. On arrival: GCS 15, BP 100/65, HR 110. He complains of left upper quadrant pain and left shoulder tip pain. FAST scan shows free fluid in Morrison's pouch. CT abdomen with contrast shows a Grade III splenic laceration with a small contrast blush.
Questions
a) What is the diagnosis and what clinical sign explains his shoulder tip pain? (2 marks)
Splenic injury Grade III with active contrast extravasation (blush). Left shoulder tip pain = Kehr's sign — hypochondrial pain referred to the left shoulder; with peritoneal irritation and haemodynamic instability it mandates urgent imaging or theatre (Bonsignore).
b) Outline the management plan for this patient. (4 marks)
- Non-operative management — EAST: NOM is the treatment of choice in haemodynamically stable patients irrespective of grade (BP 100/65 here).
- Angioembolisation — Podda: SAE is first-line in the stable patient with arterial blush on CT, irrespective of grade.
- Monitored admission — Podda: about 3 days for high-grade (AAST III–V) injuries, in a monitored setting.
- Serial haemoglobin — three successive values 8 hours apart within 10% of each other before mobilisation.
- Serial abdominal examinations for peritonitis (EAST: peritonitis still warrants laparotomy).
- LMWH VTE prophylaxis within 48–72 hours if no specific contraindication.
- Repeat CEUS/CT at 48–72 hours to detect delayed vascular complications (AAST III or higher). Not routine imaging for AAST I–II.
c) If this patient requires splenectomy, describe the post-operative vaccination protocol. (4 marks)
- Start no sooner than 14 days after splenectomy (WSES); if discharge is before day 15 and miss-risk is high, vaccinate before discharge.
- PCV13 first, then PPSV23 at least 8 weeks later (ACIP 2012, vaccine-naive asplenic adults).
- Second PPSV23 dose 5 years after the first for asplenia aged 19–64 years.
- Meningococcal and Hib cover — WSES: immunise against S. pneumoniae, H. influenzae, and N. meningitidis.
- Annual influenza vaccine (WSES: asplenic/hyposplenic patients over 6 months of age).
- Standby oral antibiotic supply (WSES adult option is amoxycillin, then levofloxacin or moxifloxacin if beta-lactam allergic) plus a medical alert bracelet; OPSI is an emergency (Davidson: immediate parenteral antibiotics and intensive care).
- Lifelong daily penicillin milligram doses are not sourced for trauma splenectomy here; Gaston OR 0.37 applies to sickle-cell children under 3 years. WSES: duration of prophylaxis is controversial; some authors recommend at least 2 years.