A  24-year-old   male   mountain  bike   rider  crashes   into   a   tree,  resulting  in   a   severe hyperextension neck injury, and  fractured lower left ribs. He now presents to hospital  with shock and a painful distending  abdomen.

b) He returns from the operating theatre after a splenectomy.  He is haemodynamically stable, but little is known of his other injuries. What is your plan for the next 24 hours?

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College Answer

At this stage stability must be confirmed in other areas as well as haemodynamic.  Blood pressure goals should consider spinal perfusion pressure if spinal injury is suspected, and steroids should be considered in the first 8 hours.

Now is the time to ensure that oxygenation and ventilation are stable; coagulation should be assessed and corrected if abnormal; and temperature should be in target range.  Secondary survey should be completed, including detailed neurologic examination (eg. in an attempt to exclude spinal injury).   Spinal precautions should be continued for the interim.   The primary x-rays should be obtained (CXR, pelvic x-ray, lateral cervical spine) but now additional x-rays should be obtained as indicated (repeat CXR, spinal series ± CTs eg. of cervical spine, chest, abdomen).   Long bone injuries should be sought and excluded (or treated).  Other specialists should be asked to review patient as indicated (eg. cardiothoracic, spinal).  Antibiotics and tetanus prophylaxis should be prescribed if indicated.  Anti-ulcer prophylaxis should be instituted, and as should pharmacological prophylaxis for DVTs when contraindications subside.  Enteral feeding should be started as soon as practical.

Discussion

This question about post-splenectomy ICU management  is identical to Question 13 from the second paper of 2005.