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Difficulty: MediumInterpreting Imaging Results

A 34-year-old man is brought to the emergency department following a high-speed skiing collision in which he struck a tree. On arrival, he is alert and oriented. His temperature is 36.8°C (98.2°F), blood pressure is 118/76 mm Hg, heart rate is 92/min, and respiratory rate is 16/min. Primary survey reveals a patent airway and bilateral breath sounds. There is severe bruising and tenderness over the left lower ribs. Abdominal examination demonstrates tenderness in the left upper quadrant with mild guarding. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a moderate amount of free fluid in the splenorenal recess. One liter of intravenous crystalloid is administered, and the patient's vital signs remain stable. A subsequent contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis is performed. It reveals a 2-cm deep splenic parenchymal laceration and moderate hemoperitoneum. Furthermore, the radiologist notes an irregular area of high attenuation within the splenic parenchyma that is visible on the arterial phase and increases in size on the delayed venous phase. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in patient management?

  1. Catheter-directed angiography with splenic artery embolizationAnswer
  2. B
    Admission to the intensive care unit for serial abdominal examinations
  3. C
    Emergent exploratory laparotomy
  4. D
    Repeat contrast-enhanced computed tomography scan in 4 hours
  5. E
    Discharge home with strict return precautions

Answer

The most appropriate next step is catheter-directed angiography with splenic artery embolization, as it provides definitive hemostasis for active splenic bleeding in a stable patient.
The correct management is catheter-directed angiography with splenic artery embolization. The key to answering this question is accurately interpreting the CT imaging results. The description of 'an irregular area of high attenuation... that increases in size on the delayed venous phase' is the pathognomonic radiologic description of active contrast extravasation, commonly referred to as a 'contrast blush'. This finding indicates active, ongoing arterial bleeding within the injured spleen. Although the patient has active bleeding, he has remained hemodynamically stable. The standard of care for a hemodynamically stable patient with blunt solid organ injury and evidence of active extravasation on CT is non-operative management via endovascular embolization. This approach achieves hemostasis while avoiding the surgical morbidity and potential immunologic consequences of an open splenectomy.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient suffered blunt abdominal trauma but remains hemodynamically stable (normal blood pressure and heart rate) after initial fluid resuscitation.
Hemodynamic stability determines whether the patient can safely undergo a CT scan or requires immediate exploratory laparotomy.
2
Interpret the specific imaging findings from the contrast-enhanced CT scan.
The CT scan describes an area of high attenuation that appears in the arterial phase and enlarges in the venous phase.
This specific radiographic pattern represents active contrast extravasation, also known as a 'contrast blush', indicating ongoing arterial hemorrhage.
3
Determine the optimal management combining the clinical stability and the imaging interpretation.
The patient needs intervention for the active bleeding, but because he is stable, he does not require open surgery.
Angiographic embolization is the standard of care for hemodynamically stable patients who exhibit active splenic bleeding on CT, as it achieves hemostasis while avoiding the morbidity of an open laparotomy.

Key Concept

In hemodynamically stable patients with blunt splenic trauma, the presence of active contrast extravasation (a 'blush') on CT imaging mandates prompt therapeutic intervention with catheter-directed angiographic embolization.
Estimated Time:1m 15s
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Interpreting Imaging Results

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