GRADE III SPLENIC TRAUMA IN AN ELDERLY PATIENT WITH HEMODYNAMIC INSTABILITY: CASE REPORT AND LITERATURE REVIEW

Abstract

Case presentation: An 80-year-old female patient was admitted to Santa Casa Hospital with a 1-week history of trauma to the left hypochondrium (LH), associated with localized pain with increasing intensity for 3 days. Physical examination revealed HR: 101 bpm, BP: 100/60, RR: 26, saturation 92%, a distended and globular abdomen with hematoma in the LH, massive to percussion, and signs of peritonitis on palpation. Computed tomography (CT) of the abdomen revealed grade IV splenic trauma and free fluid in the abdominal cavity. Thus, the patient underwent exploratory laparotomy, which identified grade III splenic trauma, with a single lesion more than 3 cm deep and active bleeding. Splenectomy was performed, with satisfactory evolution, and discharge on the 5th postoperative day. Discussion: The choice of treatment for splenic injury due to trauma involves a combination of history, physical examination, and complementary tests to identify the degree of injury. In the case presented, the patient suffered blunt trauma with grade III splenic injury. The diagnosis was possible through clinical evaluation, hematoma in the left hemisphere region, and hemodynamic instability, identified by grade III hypovolemic shock, which guided the complementary tests. Contrast-enhanced CT is the gold standard for evaluation in hemodynamically stable patients, as it allows identifying the extent and severity of the injury and associated visceral trauma, in addition to defining the treatment. This corroborates the case described, where a definitive diagnosis was reached after CT, which identified splenic injury with free fluid in the abdominal cavity, determining the therapeutic approach. In grade IV splenic trauma, there is significant vascular injury, characterized by laceration of segmental or hilar vessels, resulting in devascularization of more than 25% of the spleen, and may present with active bleeding confined to the splenic capsule. Because this is a grade IV injury associated with hemodynamic instability, surgical intervention was immediately indicated. However, intraoperatively, a grade III splenic injury was identified, but the management was not changed due to shock and lack of response to fluid replacement. Exploratory laparotomy is the gold standard in the treatment of patients with blunt abdominal trauma who present hemodynamic instability, as discussed in the reported case, which had a satisfactory outcome. Final comments: The appropriate management of splenic trauma depends on clinical evaluation, imaging studies, and injury classification. This case demonstrates the effectiveness of damage control and the decisive role of timely surgical management in survival.