Case #88 "Do you remember that patient?"
by Charlene Babcock Irvin, MD, FACEP  

As I came on to a busy summer evening sign-out at a smaller hospital, one of the nurses commented to me: “Do you remember that patient you transferred with the femur fracture to the trauma center? Well she died from a splenic rupture!” I did remember that patient. It was only 3 weeks ago, and I don’t work very often at this small hospital. It doesn’t have the capabilities for major traumas, so they all are transferred out to trauma centers.
“How did you find out?” I asked

“She used to work for my cousins brother-in-law and he told me.” She answered.

As you can imagine, this is not the best way to start an overnight 12-hour shift at a small and busy ED.

The patient had been at a park, when her boyfriend got into a fight with someone else. She got between them, and during the tussle, she was pushed into a picnic table, hitting her torso on the table, her hip on the seat, and then those fighting fell onto her legs. She heard the snap when they hit her femur.

She came in slightly hypotensive (blood pressure in the 90’s) and tachycardic (HR in the 110-120’s), crying and complaining of severe pain in her femur. She was also intoxicated.

I remember I thought she had clinical rib fractures on the left lower chest (CXR did not show any pneumothorax or reveal the rib fractures, but she was very tender there). I remember thinking about the spleen based on her mechanism and her posterior–lateral left rib pain, but she had absolutely no abdominal pain (and I remember checking several times).

After applying a hare traction splint, and a little morphine, she was much more comfortable. Her initial labs were unremarkable (mild anemia with Hbg around 11). Alcohol level was 100 mg/dl-- not very drunk. She was transported to the trauma center with the splint on, and I never heard anything else until now.

Questions:

1. Why didn’t her initial labs reflect the blood loss from the splenic injury?

2. Fat embolism syndrome usually occurs after a long bone fracture such as a femur shaft fracture. Will this happen in the ED? How is it diagnosed? How is it treated?

3. What are the different grades of splenic injuries, and what are the different treatment options?

4. How common is delayed presentation of splenic injury?

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