A 39-year-old American society of Anaesthesiology stage 1, body mass index 23 kgm− 2, South Asian female presented to the emergency department (ED) of a District General Hospital in Sri Lanka with atypical chest pain and left shoulder pain for three days’ duration. She did not disclose any autonomic features, difficulty in breathing, or cough with fever. On examination, she was not pale. Her cardiorespiratory parameters were stable (Non-invasive blood pressure 112/67mmHg, pulse rate 88 per minute, peripheral oxygen saturation, 98% on room air and respiratory rate, 16 per minute). She denied any history of trauma. There was no localized tenderness over the chest. The COVID-19 rapid antigen test was negative. The ECG showed ‘T’ inversions in inferior leads (lead II, II and aVF). Troponin I titer was negative. Chest X-ray was normal. She was diagnosed as having unstable angina considering her persistent symptoms. Loading doses of oral aspirin 300 mg, clopidogrel 300 mg, and atorvastatin 40 mg were prescribed with 60 mg subcutaneous enoxaparin twice a day. Subsequently, she was transferred to the medical unit. The repeated ECG did not reveal any dynamic changes. During the ward stay, she complained of persistent symptoms for which sublingual glyceryl trinitrate was administered. Rest of the blood investigations yielded normal results. Eighteen hours after admission, a sudden haemodynamic collapse was witnessed. Her blood pressure dropped to 70/40mmHg and pulse rate increased to 120 per minute with very low volume. She was found to be severely pale. The repeated haemoglobin level was 3.8 g/dl. Immediate resuscitation was commenced with supplemental oxygen. Massive transfusion protocol with transfusion of blood and blood products was initiated. Further history revealed that the patient had an accidental fall onto a hard surface from an approximate height of 2 feet with impact on her left loin around the time of onset of the presenting symptoms. An ultrasound scan of the abdomen revealed a splenic laceration with expanding subscapular haematoma and haemoperitoneum. Following heamatology opinion, intravenous Tranexamic acid 10 mg/ kg and Protamine sulfate 1mg/ kg was administered. Details of the results of the initial and subsequent investigations are illustrated in Table 01.
She was taken to the operating theater for emergency exploratory laparotomy. On induction, her blood pressure was 92/65mmHg and her pulse rate was 100 per minute. She was induced with intravenous ketamine 50 mg, midazolam 1 mg, and fentanyl 75 mics. During the surgery, two linear lacerations extending from the capsule to the hilum were detected in the mid part of the spleen with a large haematoma accountable for the American Association for the Surgery of Trauma (AAST) grade 4 splenic injury with an estimated progressive blood loss of 3.5L which warranted urgent splenectomy with ongoing massive blood transfusion. Spleen was found to be congested with an approximate size was 10 cm* 6 cm * 5 cm (Fig. 1a, b).
Massive transfusion was continued requiring 6 units of packed red cells, 600 ml of fresh frozen plasma, 20 units of cryoprecipitate, and an adult pool of platelets. Splenectomy was performed by the surgical team. There was no other visceral organ injury. Haemostasis was achieved and the patient was admitted to the intensive care unit. Clotting parameters were assessed by way of prothrombin time, activated partial thromboplastin time, and platelet count due to the unavailability of point of care testing. All yielded normal results. Ten hours later, with stable haemodynamics and normalized arterial blood gas analysis, the trachea was extubated. Her ECG changes reverted back to normal within 24 hours. On postoperative day two, she was transferred back to the ward. 2d echocardiogram did not reveal regional wall motion abnormalities. A coronary angiogram was arranged on outpatient basis after 2 weeks, which revealed normal coronary vasculature. Lipid profile and fasting blood sugar level were normal. Spleen weighed 150 g which was normal for age and sex. Histology of the spleen did not reveal chronic abnormalities (Fig. 2a, b).
The patient was regularly followed up in the surgical clinic, with pneumococcal, meningococcal, and haemophilus influenzae b vaccinations arranged at 2 weeks. At one-year follow-up, she had been devoid of any life-threatening sepsis or any other surgery-related complications. Screening for Epstein-Barr virus, Cytomegalovirus, Human immunodeficiency virus, Hepatitis A/B/C, and malaria were negative. Following the incident, ED doctors were briefed on the sequence of events. The necessity of complete history, examination with increased vigilance on trauma were reiterated and the exclusion of probable differential diagnoses by relevant history, clinical examination and utility of subsidiary investigations such as bedside FAST, whenever appropriate, was encouraged especially in presentations with atypical chest pain.