01Approach to the Critical Patient/attcp46

Immediate priorities

›Life threats and stabilization

›Airway compromise

›If refractory hypoxemia or inability to protect airway, intubation

›Breathing threats

›If tension pneumothorax physiology, immediate decompression

›Circulatory collapse

›If SBP <90 mm Hg with suspected intraabdominal hemorrhage, resuscitation bay escalation

›Hemorrhagic shock recognition

›Persistent tachycardia despite analgesia

›Narrow pulse pressure

›Cool clammy skin

›Altered mental status without head injury explanation

›Early hemorrhage control pathway

›If unstable with positive FAST, immediate operative management pathway

›If unstable with negative FAST, alternate bleeding sources pathway

Hemodynamic goals and monitoring

›Monitoring and targets

›Continuous ECG and pulse oximetry

›Frequent reassessment for evolving shock

›Two large bore IV or IO access

›If difficult access, rapid IO placement

›Blood pressure strategy

›If active hemorrhage suspected, permissive hypotension until hemostasis when no TBI

›If traumatic brain injury suspected, maintain adequate cerebral perfusion and avoid hypotension

›Temperature control

›Active warming to prevent coagulopathy

›Urine output monitoring

02History/hx42

Mechanism and timing

›Injury context

›Blunt trauma mechanism

›Motor vehicle collision

›Fall from height

›Sports impact

›Penetrating trauma mechanism

›Left upper quadrant or lower chest wound trajectory

›Flank wound trajectory

›Time since injury

›Delayed presentation risk

Symptoms and associated features

›Symptom pattern

›Left upper quadrant abdominal pain

›Worsening with movement

›Left shoulder pain

›Kehr sign suggestion of diaphragmatic irritation

›Dizziness or syncope

›Hemorrhage concern

›Dyspnea

›Associated lower chest injury concern

›Nausea or vomiting

›Abdominal irritation or associated injury

Risk modifiers and medications

›Bleeding risk context

›Anticoagulant use

›Warfarin

›DOACs

03Physical Exam/exam42

Primary survey focused findings

›Immediate exam priorities

›Hemodynamic status

›Hypotension

›Tachycardia

›Mental status

›Agitation or confusion as shock marker

›Respiratory status

›Tachypnea

›Low oxygen saturation

Abdominal and thoracoabdominal exam

›Abdominal injury clues

›Left upper quadrant tenderness

›Guarding

›Rebound

›Abdominal distension

›Increasing girth concern

›Peritonitis

›Rigidity

›Severe diffuse tenderness

›External signs

›Seatbelt sign

›Abdominal wall ecchymosis

Chest wall and rib assessment

›Lower chest injury association

›Left lower rib tenderness

›Rib fracture association with splenic injury

›Chest wall crepitus

04Differential Diagnosis/ddx29

Life threatening traumatic causes

›Hemorrhagic sources

›Splenic laceration or rupture (ICD 10 S36.0)

›Hemoperitoneum

›Liver laceration (ICD 10 S36.1)

›Right upper quadrant dominant pain

›Mesenteric injury (ICD 10 S36.8)

›Delayed peritonitis

›Hollow viscus perforation (ICD 10 S36.5)

›Free air risk

›Retroperitoneal hemorrhage

›Pelvic fracture association

Mimics and related conditions

›Non splenic explanations

›Left renal injury (ICD 10 S37.0)

›Flank pain

›Hematuria

›Pancreatic injury (ICD 10 S36.2)

›Epigastric pain

›Delayed elevation of enzymes

›Left lower rib fracture pain (ICD 10 S22.3)

›Focal chest wall tenderness

›Hemothorax (ICD 10 S27.1)

›Dullness and decreased breath sounds

Non traumatic abdominal pain differentials

›Alternative diagnoses

›Splenic infarction

›Atrial fibrillation context

05Laboratory Tests/lt32

Hemorrhage and perfusion labs

›Bleeding and shock assessment

›Complete blood count for bleeding concern

›Hemoglobin trend over time

›Platelet count for coagulopathy context

›Venous blood gas for perfusion

›Lactate mmol/L as shock marker

›Base deficit as severity marker

›Basic metabolic panel

›Creatinine for contrast planning

›Potassium for resuscitation safety

Coagulation and transfusion preparation

›Hemostasis and blood products

›INR and aPTT

›Anticoagulant effect estimate

›Trauma induced coagulopathy context

›Fibrinogen

›Low fibrinogen as massive hemorrhage marker

›Type and screen

›Early crossmatch readiness

›Pregnancy test when applicable

›Imaging and management implications

Point of care and adjunct tests

›Rapid adjuncts

›Point of care hemoglobin

›Trend support only

›Early false reassurance risk

›Thromboelastography or rotational thromboelastometry when available

06Diagnostic Tests/dt62

Scoring Systems

›Injury grading and classification

›AAST splenic injury scale

›Grade I

›Subcapsular hematoma less than 10 percent surface area

›Capsular laceration less than 1 cm depth

›Grade II

›Subcapsular hematoma 10 to 50 percent surface area

›Intraparenchymal hematoma less than 5 cm

›Laceration 1 to 3 cm depth without trabecular vessel involvement

›Grade III

›Subcapsular hematoma more than 50 percent surface area or expanding

›Ruptured subcapsular or parenchymal hematoma

›Intraparenchymal hematoma 5 cm or larger or expanding

›Laceration more than 3 cm depth or involving trabecular vessels

›Grade IV

›Laceration involving segmental or hilar vessels with major devascularization more than 25 percent

›Grade V

›Shattered spleen

›Hilar vascular injury with devascularized spleen

›WSES splenic trauma classification

›Combines AAST grade and hemodynamic status

›Guides nonoperative vs operative strategy

›Shock index

›Heart rate divided by systolic blood pressure

›Elevated values suggest occult shock

MRI

›Limited role in acute trauma

07Disposition/dispo31

Level of care selection

›Admission and monitoring strategy

›ICU level care

›Hemodynamic instability or vasopressor need

›Ongoing transfusion requirement

›High grade injury with high risk of delayed bleeding

›Stepdown or ward care

›Stable vitals with low grade injury

›Reliable serial exams capability

›Observation unit

›Selected low grade injuries with stable hemoglobin trend and pain control

Transfer and resource needs

›System requirements

›Trauma surgery capability

›Operative management availability

›Interventional radiology availability

›Angioembolization access within clinically acceptable time

›Blood bank support

›Massive transfusion capability

Discharge eligibility

›Discharge criteria

›Hemodynamic stability without transfusion need

›Stable serial vitals

›Stable hemoglobin trend

›No clinically significant drop over observation period

›Pain controlled on oral regimen

›Ambulation feasible

›Reliable follow up and return precautions

08Treatment/t78

Resuscitation and transfusion

›Hemorrhage resuscitation

›Balanced blood product strategy

›Early packed red cells and plasma consideration in major hemorrhage

›Avoid large volume crystalloid as primary strategy

›Platelet support when massive transfusion context

›Goal directed therapy when viscoelastic testing available

›Massive transfusion protocol

›If suspected life threatening hemorrhage, activate early

›Hypothermia prevention integrated

›Tranexamic acid

›If within 3 hours of major traumatic bleeding, consider

›1 g IV over 10 minutes

›Then 1 g IV over 8 hours

Nonoperative management pathway

›Observation strategy in stable patient

›Bed rest and activity restriction protocol per local policy

›Serial abdominal exams

›Worsening tenderness escalation

›Serial hemoglobin monitoring

›Increasing transfusion need escalation

›DVT prophylaxis timing

›Mechanical prophylaxis early

›Pharmacologic prophylaxis when bleeding stabilized per trauma protocol

›Analgesia

›Multimodal regimen

›Acetaminophen scheduled when appropriate

›Opioid sparing strategy

›Opioids for breakthrough pain

›Monitor for hypotension and hypoventilation

Angiography and embolization

›Splenic angioembolization indications

›CT contrast extravasation or blush in stable patient

›IR consultation for embolization

›Splenic vascular lesions

›Pseudoaneurysm

›Arteriovenous fistula

›High grade injury with substantial hemoperitoneum

›Adjunct to nonoperative management

›Embolization considerations

›Proximal vs distal embolization

›Proximal for diffuse bleeding risk reduction

›Distal for focal vascular lesion

›Post embolization monitoring

›Rebleeding signs

›Splenic infarction symptoms

Operative management

›Surgery indications

›Hemodynamic instability from suspected intraabdominal bleed

›Immediate laparotomy pathway

›Peritonitis

›Hollow viscus or uncontrolled hemorrhage concern

›Failed nonoperative management

›Ongoing transfusion requirement

›Worsening hemodynamics

›Operative options

›Splenorrhaphy or partial splenectomy

›Spleen preserving strategy when feasible

›Splenectomy

›Definitive hemorrhage control

Postsplenectomy and functional asplenia care

›Infection prevention

›Vaccination strategy

›Pneumococcal vaccination series per local schedule

›PCV followed by PPSV timing per guidance

›Meningococcal vaccination

›MenACWY series

›MenB series

›Haemophilus influenzae type b vaccine

›Single dose if not previously immunized

›Antibiotic considerations

›Febrile illness low threshold for empiric antibiotics and urgent evaluation

›Standby antibiotics policy dependent

›Thrombosis risk

›Postsplenectomy thrombocytosis monitoring

›Platelet trend follow up

Evidence levels and consensus

›Evidence framing

›Hemodynamically unstable abdominal trauma with suspected hemorrhage favors operative hemorrhage control

›Class I recommendation based on expert consensus

›CT with IV contrast for stable blunt abdominal trauma when solid organ injury suspected

›ACEP Level C consensus support for imaging guided management in trauma systems

›eFAST as rapid adjunct in hypotensive trauma

›ACEP Level C consensus support as bedside decision aid

09Special Populations/sp24

Pregnancy

›Pregnancy specific considerations

›Physiologic tachycardia and lower baseline blood pressure

›Occult shock risk

›Left upper quadrant pain differential broadening

›Placental abruption if trauma with uterine tenderness

›Imaging strategy

›Maternal stabilization priority

›CT when clinically indicated despite fetal radiation concern

›Rh status

›Anti D immunoglobulin when indicated

Geriatric

›Older adult considerations

›Blunted tachycardic response

›Beta blocker use masking shock

›Anticoagulant and antiplatelet prevalence

›Lower threshold for imaging and reversal considerations

›Frailty and comorbidities

›Lower physiologic reserve for hemorrhage

Pediatrics

›Pediatric management themes

›Nonoperative management high success in stable children

›Close monitoring and serial exams

›Weight based resuscitation

›Blood products and medications dosed per kg

›Activity restriction

›Return to sports timing guided by grade and pediatric trauma protocol

10Background/b25

Epidemiology

›Frequency and context

›Splenic injury as common solid organ injury in blunt abdominal trauma

›Association with motor vehicle collisions and falls

›Concomitant injuries common

›Rib fractures

›Pulmonary contusion

›Traumatic brain injury

Pathophysiology

›Mechanisms of injury

›Capsular tear and parenchymal laceration

›Hemoperitoneum risk

›Vascular injury

›Pseudoaneurysm formation

›Active arterial bleeding

›Subcapsular hematoma expansion

›Delayed rupture risk

Therapeutic Considerations

›Management principles

›Hemodynamic status as primary decision driver

›Stability favors imaging guided nonoperative pathway

›Spleen preservation value

›Reduced risk of overwhelming postsplenectomy infection

›Angioembolization role

›Adjunct to improve nonoperative success in vascular injury patterns

›Complication tradeoffs

›Rebleeding vs infarction vs abscess risk after embolization

›Lifelong infection risk after splenectomy

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge guidance

›Return to emergency care immediately for worsening abdominal pain

›New shoulder pain

›Return to emergency care immediately for dizziness or fainting

›New weakness or confusion

›Return to emergency care immediately for vomiting blood or black stools

›Any uncontrolled bleeding

›Return to emergency care immediately for fever

›Special urgency if spleen removed or not functioning

›Activity restriction

›No contact sports until cleared by trauma team

›No heavy lifting until cleared

›Follow up plan

›Trauma clinic appointment timing per local protocol

›Repeat imaging only if directed

›Postsplenectomy specific instructions when applicable

›Vaccination schedule follow up

›Medical alert identification for asplenia

›Early medical evaluation for any febrile illness

12References/r14

Clinical guidelines and consensus sources

›Trauma and solid organ injury guidance

›ATLS principles for hemorrhagic shock and abdominal trauma management

›Hemodynamic status driven operative decision making

›Eastern Association for the Surgery of Trauma guidelines on nonoperative management of blunt splenic injury

›Angioembolization considerations for vascular injury patterns

›World Society of Emergency Surgery splenic trauma classification and management recommendations

›Integration of grade and physiology

Evidence based sources

›Foundational evidence

›AAST organ injury scale for splenic trauma

›Standardized grading framework

›Major observational studies on nonoperative management success and predictors of failure

›Higher risk with vascular blush and high grade injury

›Postsplenectomy infection prevention recommendations

›Vaccination and fever response pathways

Evidence & Review

Evidence & Review