Article, Ultrasound

Bedside ultrasound diagnosis of a spontaneous splenic hemorrhage after tissue plasminogen activator administration

ultrasound diagnosis of a sponta”>Case Report

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American Journal of Emergency Medicine

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Bedside ultrasound diagnosis of a spontaneous splenic hemorrhage after tissue plasminogen activator administration

Abstract

Emergency physicians (EPs) can use bedside ultrasound to diagnosis of intraabdominal free fluid in a variety of clinical scenarios.

The purpose of this study is to review the sonographic appearance of intraabdominal free fluid and incidence of Spontaneous splenic rupture.

An EP used bedside ultrasound to diagnose spontaneous splenic rupture in a patient who had received tissue plasminogen activator for suspected acute ischemic stroke.

Bedside ultrasound by a physician trained in basic ultrasound and the focused assessment with sonography for trauma can diagnose intraabdominal free fluid, facilitating appropriate and more rapid consultation, advanced imaging, and treatment.

We report a case of a spontaneous post-tissue plasminogen activator splenic hemorrhage that was diagnosed by an emergency physician performing a bedside focused assessment with sonography for trauma examination. Bedside ultrasound can be used to diagnose the presence of intraabdominal free fluid, which in the right Clinical context may indicate intraAbdominal hemorrhage.

An 89-year-old woman was transferred to our emergency department (ED) from an outside hospital after having received tPA for acute onset of aphasia accompanied by right upper Extremity weakness and right-sided facial droop. Her National Institutes of Health Stroke Scale was calculated at 3, and tPA was subsequently administered after speaking with our institution’s telestroke service. After the administration of tPA, she was transferred to our ED for further treatment.

Shortly upon arrival to the ED, her vital signs were recorded as a blood pressure of 170/72 mm Hg, heart rate of 70 beats per minute, respiratory rate of 18 breaths per minute, and an oral temperature of

97.8?F. The patient was alert and oriented to person and place. Her neurologic examination was notable for dysarthria and nasolabial fold flattening on the left. She also had difficulty raising her right upper extremity, but no clear pronator drift was appreciated.

A computed tomographic (CT) angiogram of the head and neck was performed, which did not reveal vessel cut-off. Thus, she was transported to the magnetic resonance imaging (MRI) suite for further imaging per request of the neurology consultant. While undergoing the MRI, the patient became increasingly hypotensive, pale, and diaphoretic. She was immediately brought back to the ED for emergent reevaluation and resuscitation. As part of the initial evaluation for hypotension of unclear etiology, the EP performed a bedside FAST examination. A large amount of free fluid was detected in both the right upper quadrant (Fig. 1) and the left upper quadrant (Fig. 2), concerning for intraabdominal hemorrhage. An abdominal CT scan subsequently revealed perisplenic fluid concerning for an acute

Fig. 1. View of left upper quadrant using FAST examination. On left of window, the spleen is noted with kidney directly to the right. An anechoic area is evident surrounding the spleen (see arrow), which confirms the presence of free fluid.

perisplenic hematoma, confirming the initial Sonographic findings (Figs. 3 and 4). A Surgical consultation was obtained in the ED, and the patient was conservatively managed with a medical admission for monitoring and serial Abdominal examinations. Ultimately, no operative intervention was required.

Fig. 2. Right upper quadrant view during the FAST examination. The area between the kidney and liver is known as Morison’s Pouch, the most dependent area in the abdomen in a Supine patient and the most likely area for free fluid to accumulate. As seen above, there is a thin stripe of anechoic fluid between the kidney and liver, confirming the presence of free fluid.

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Fig. 3. Coronal section of CT abdomen/pelvis. As depicted above, there is an area of hypoattenuating fluid concerning for hemorrhage (see arrow).

Fig. 4. Axial vew of CT abdomen and pelvis. Again, there is an area of hypoattenuating

fluid surrounding the spleen, concerning for hemorrhage without active extravasation.

Although EPs are well versed in post-tPA complications, sponta- neous splenic hemorrhage is very rare. A literature review revealed 13 described cases of spontaneous splenic hemorrhage after thromboly- tic administration [1]. One such case involved an elderly female patient who received an infusion of Intravenous heparin after she was diagnosed with a myocardial infarction. She developed a spontaneous splenic hemorrhage, which was treated conservatively [1].

Traumatic splenic rupture is certainly a more common phenom- enon and was first described in 1931 by McIndoe [2] more than 48 hours after the initial Traumatic event. Because of the morbidity associated with splenectomy (such as pneumonia, subphrenic abscess, and pancreatitis), conservative management is currently favored. Splenic artery embolization is usually reserved for unstable patients who fail conservative treatment. Of note, delayed splenic rupture has also been reported with a mean of 13 days postinjury and may be related to the delayed rupture of either a hematoma or a posttraumatic pseudoaneurysm that had initially tamponaded and subsequently ruptured [3]. Because of this known complication, patients must be given strict return instructions. Interestingly, delayed splenic rupture is rarely evident with major trauma and is much more likely to occur with what would be considered a “minor” trauma such as a fall from standing in an elderly patient.

The bedside FAST examination is a well-documented approach to diagnose intraabdominal free fluid. Specifically, the EP can use bedside ultrasound to assess several dependent portions of the intraabdominal cavity in a supine patient. The right upper quadrant view assesses Morison’s Pouch, the potential space between the kidney and liver. The left upper quadrant view examines the recess between the kidney and spleen. The pelvic view is used to assess for fluid posterior to the bladder. Finally, the subxiphoid view assesses for the presence of a pericardial effusion [4,5]. On ultrasound, intraab- dominal free fluid appears hypoechoic and in the right clinical context, such as trauma, indicates the presence of blood [4,5]. Ultrasound is quite sensitive and specific for the detection of intraabdominal fluid, 73% to 88% and 98% to 100%, respectively and

therefore can be used as an efficient diagnostic tool in the unstable or hypotensive patient to provide a potential explanation for their hypotension [6].

We report a case in which the EP used a bedside FAST examination to diagnose a spontaneous splenic rupture shortly after tPA administration in a hypotensive patient.

Alissa Genthon, MD Massachusetts General Hospital, Boston, MA E-mail address: [email protected]

Sarah Frasure, MD Brigham and Womens Hospital, Boston, MA E-mail address: [email protected]

Karen Kinnaman, MD Calvin Huang, MD Vicki Noble, MD

Massachusetts General Hospital, Boston, MA E-mail addresses: [email protected] (K. Kinnaman), [email protected] (C. Huang), [email protected] (V. Noble)

http://dx.doi.org/10.1016/j.ajem.2014.04.015

References

  1. Aubrey-Bassler F, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emerg Med 2012;12:11.
  2. McIndoe AH. Delayed haemorrhage following traumatic rupture of the spleen. Br J Surg 1931;20:249-67.
  3. Liu P, et al. nonsurgical management of delayed splenic rupture after blunt trauma. J Trauma 2012;72:1019-22.
  4. Noble, et al. Manual of emergency and critical care ultrasound; 2007 23-30.
  5. Rose JS. Ultrasound in abdominal trauma. Emerg Med Clin North Am 2004;22 (3):581-99.
  6. Dawson M, Mallin M. Introduction to bedside ultrasound: volumes 1 and 2. FAST/ EFAST; 2014.

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