Traumatic Splenic Rupture in a High School Baseball Player with Undiagnosed Infectious Mononucleosis.

1. Traumatic Splenic Rupture in a High School Baseball Player with Undiagnosed Infectious Mononucleosis. Presented by Lori Miller, MS, ATC, LAT, CSCS

2. Case History Background Info 15 yrs old male baseball player 2nd baseman Traveling team

3. Case History Background Info Had been feeling “under the weather”for about a week or so before the tournament, but did not go to the doctor. Took vitamin C and echinaca herbs. Played 4 innings at second base without problems. Pop-fly ball hit towards second base, the 2nd base man ran backwards as the centerfielder ran upwards.

4. Case History Background Info Collision just behind second base ~10ft CF’s left knee into 2nd baseman’s abdominothoracic area below the ribs from behind. Both fell to the ground, both immediately jumped up and went back to positions, 2nd base looked a little confused,with hand on back.

5. Case History Background Info ATC inquired as to status, athlete denied pain,said it stung for a second, he clearing his head and was fine. Refused evaluation at this time. Athlete finished the inning, then came over to sit in the dugout as his team was up to bat.

6. Case History Background Info ATC noticed athlete sitting “funny” and looked uncomfortable. Once again, the ATC attempted to check his status. First he denied all pain and nausea. A few minutes later, the ATC checked him again and the athlete stated he felt a little “woozy” and agreed to be evaluated.

7. Evaluation & Assessment On-field Management Visually inspected the impact area to find a small area of redness at the site of impact. Palpation of the area elicited only slight tenderness. The athlete agreed to lie supine on the bench in the bent knee position for palpation of the abdomen. The was muscle guarding and some rigidity in the upper left quadrant,with some increasing discomfort in the ULQ. No Kehr’s sign at this time.

8. Evaluation & Assessment On-field Management Vitals were assessed and recorded,and the athlete was covered with a blanket to avoid a drop in body temperature. The athlete did not have a low systolic reading, however, he began to exhibit signs of increasing HR (tachycardia), and RR (tachynpea) with more deliberate breaths. Pulse was still moderately strong at this time. Level of consciousness was also monitored.

9. Evaluation & Assessment On-field Management The athlete was kept calm and warm in the above mentioned position, as EMS was dispatched.

10. Evaluation & Assessment On-field Management Approximately 20-30 minutes post trauma, the athlete had a positive Kehr’s sign, and his vitals were beginning to show increased signs of internal bleeding, including a reduction of systolic pressure. EMS arrived, vital information relayed, the athlete was spine-boarded and transported to the nearest emergency facility.

11. Important Points of On-field Assessment/Mgmt Vitals –HR,RR,BP—body temp. –pain Positioning Monitoring the trends in vital signs is essential for abdominal trauma/spleen injury to accurately assess and re-assess the status of the athlete.

12. Important Points of On-field Assessment Internal trauma with bleeding can quickly put an athlete into a state of hypovolemic shock. Changes in the vitals can indicate distress and quantitatively indicate the level of progressing hemodynamic instability.1, 2, 5, 12

13. Important Points of On-field Assessment HR&RR, which are easily monitored and can tell the ATC a great deal about what is happening with this athlete.

14. Important Points of On-field Assessment The heart rate that is increasing is a “red flag” that the body is in a state on ongoing blood loss and/or shock and the tachycardia is in response to the heart having to work harder to perfuse the tissues. The exception to this is an athlete who is on a calcium channel blocker or beta-blocker, which could prevent the body from using this compensatory response.1, 5, 11, 12

15. Important Points of On-field Assessment   As in the increased heart rate, an increased respiratory rate is also a danger sign. Tachypnea is how the body compensates for the diminished oxygen carrying capability due to red blood cell loss (hemoglobin).

16. Important Points of On-field Assessment If the patient develops hypovolemic shock, the decline in tissue perfusion will increase lactic acid production, causing anaerobic metabolism and metabolic acidosis. The tachypnea worsen as the body attempts to expel the excess carbon dioxide.5, 12, 13

17. Important Points of On-field Assessment Blood pressure is another vital that is monitored, but it not the foremost indicator of bleeding.

18. Important Points of On-field Assessment Slow steady reduction of systolic pressure from bleeding can give a normal reading for a limited time through sympathetic nervous system and the rennin angiotensen-aldosterone system input.

19. Important Points of On-field Assessment This response causes a raise in heart rate and a constriction of peripheral blood vessels.12, 13 The kidneys will hold water and sodium in an effort to reduce fluid loss, and this will help maintain BP also. By the time the athlete shows a hypotensive systolic reading of 90mmHg or less, they are already in a state of uncompensated shock that must be immediately reversed with blood products and fluids.5, 7

20. Important Points of On-field Assessment Temperature can be monitored, but it is more important in an emergency situation with bleeding that the athlete be kept warm, still, and calm. Always monitor and record the athlete’s level of consciousness, looking for changes such as orientation, restlessness, or even agitation. These changes, even if subtle can be an indication of inadequate perfusion or hypoxemia.

21. Important Points of On-field Assessment Level of pain should be continually re-assessed and recorded as far as type, intensity, location, unrelieved or worsening. Persistent nausea or vomiting can occur and indicate severe hemorrhage with possible damage to other internal organs.12, 13 All available vital information is given to the EMS or the Emergency Facility the athlete is transported to.

22. Important Points of On-field Assessment Temperature can be monitored, but it is more important in an emergency situation with bleeding that the athlete be kept warm, still, and calm. Always monitor and record the athlete’s level of consciousness, looking for changes such as orientation, restlessness, or even agitation. These changes, even if subtle can be an indication of inadequate perfusion or hypoxemia. Level of pain should be continually re-assessed and recorded as

23. Important Points of On-field Assessment The athlete with blunt splenic trauma can present in a variety of ways, with some patients being asymptomatic, or present with extreme symptoms. Recognizing splenic trauma before the patient becomes significantly symptomatic is imperative. If the mechanism of injury is a blunt direct blow to the abdomen or even the posterior thorax, this injury must be recognized or ruled out for the safety of the athlete.

24. Important Points of On-field Assessment An athlete with an injury to the spleen will normally complain of acute onset pain, this could be in the abdomen specifically, as there are pain fibers in the splenic capsule, or can be a referred pain or strange sensation to the left upper arm, shoulder (top), or neck, commonly called Kehr’s sign.2, 5, 9, 10, 11

25. Important Points of On-field Assessment Some muscle guarding and rigidity in the abdomen will normally accompany the pain. The abdomen may or may not be distended or discolored, depending upon who much bleeding is occurring and if it is contained by the outer covering or the spleen.

26. Important Points of On-field Assessment Visual signs of internal bleeding can be manifested as Cullen’s sign if in the umbilical area, or Turner’s sign if seen on the lateral abdominal wall.2 The Kehr sign appears as a result of the irritation of the diaphragm and phrenic nerve from the free blood pooling in the abdominal cavity.5, 11 The abdominal peritoneum will be highly irritated by the blood and will stimulate the pain response.

27. Important Points of On-field Assessment The intensity and timing of the Kehr’s sign can be an indication as to how fast an athlete might be bleeding.10 Sometimes the athlete might also complain of nausea, dizziness, light-headedness, and may feel the urge to defecate.2, 5, 9, 10

28. Treatment Rendered The athlete was found to have a small rupture in the posterior portion of the spleen that was actively bleeding. Emergency surgery was performed and the spleen was repaired, (splenorraphy) and the 1900mL of blood that was found in the abdomen was auto-transfused back into his circulation.

29. Treatment Rendered During the course of evaluation and blood work, it was determined that this athlete had an undiagnosed active case of infectious mononucleosis.

30. Treatment Rendered According to the surgeons, his spleen did have some early signs of clustering white cells (enlargement), possibly from the mono, which might have been a precipitating factor for the ease of rupture. While healing, this athlete then developed a post operative sepsis infection in the hospital and was treated for such.

32. Differential Diagnosis Kidney Rupture Kidney Laceration Splenic Rupture Splenic Laceration Splenic Artery Avulsion Ruptured Viscus

34. Anatomy and Function of the Spleen The human spleen is a dark bean shaped organ about the size of a person’s fist and weighing approximately 5-6 ounces and located in the upper left quadrant, just beneath the diaphragm and posterior to the stomach. The shape and structure of the spleen is similar to a lymph node, but much larger. This makes the spleen the largest lymphatic organ in the body.

35. Anatomy and Function of the Spleen The spleen is protected by the rib cage anteriorly, laterally, and posteriorly. Physically the spleen is in contact with other vital organs, specifically the left diaphragm superiorly, the pancreatic tail medially, the stomach anteromedially, the left kidney and adrenal gland posteromedially, as well as the flexure of the colon inferiorly.5, 7

36. Anatomy and Function of the Spleen To keep its position in the upper left quadrant, the spleen is secured by four suspensory ligaments: the gastrosplenic, which connects the stomach to the spleen; the splenorenal, which connects the spleen to the kidney; the splenocolic, which connects the spleen to the colic flexure and to the thoracic diaphragm; and the splenophrenic, which connects the spleen to the diaphragm.

37. Anatomy and Function of the Spleen The spleen is surrounded by a connective tissue capsule, called trabeculae, which extends inward to divide the organ into lobules (compartments).7 Two types of tissue are found in the spleen which correspond to its two most important functional roles. This tissue is called white pulp and red pulp.

38. Anatomy and Function of the Spleen The white pulp is lymphatic tissue consisting mainly of B& T-lymphocytes around the arteries with the purpose of immunity and phagocytic action.

39. Anatomy and Function of the Spleen The red pulp consists of venous sinuses filled with blood and cords of lymphatic cells, such as lymphocytes and macrophages, which is the primary site for mechanical filtration of the blood and the removal of senescent red blood cells.6, 7, 8 Perfusion of the spleen is via the splenic artery to each individual segment, as blood moves through the sinuses, it is filtered, then leaves through the splenic vein.

40. Anatomy and Function of the Spleen The spleen filters blood very similar to the way a lymph node filters lymph fluid. Pathogens that are encountered in the blood stimulate the spleen lymphocytes to attack and destroy them. Macrophages then are stimulated to engulf the debris, damaged cells, and other large particles thru phagocytic activity.

41. Anatomy and Function of the Spleen Like other lymphatic tissue, the spleen produces lymphocytes; particularly in response to invading pathogens.6, 8 The sinuses in the spleen are the sites for storing reserve blood. The spleen filters an estimated 10% to 15% of a persons total blood volume every minute and holds and estimated 25% of the circulating platelets in reserve.

42. Anatomy and Function of the Spleen At any given time, 1 unit or ~450mL of blood is contained in the spleen.2 In emergencies, such as a hemorrhage, smooth muscle in the vessel walls and in the capsule of the spleen contracts due to sympathetic stimulation, and squeezes ~200mL of reserved blood out of the organ into general circulation.

44. Facts Relating to IM Infectious Mononucleosis, “mono” for short, is caused by the Epstein-Barr virus (EBV). The Epstein-Barr virus is a member of the herpes family and is carried in the salivary glands. The virus is spread by direct intimate contact such as kissing, and is frequently called the “kissing disease”. Airborne transmission of the virus is poor, so the risk of contamination to others is low.5 It is easier to catch the common cold.

45. Facts Relating to IM There are four major symptoms typically associated with mononucleosis that tend to mimic flu-like symptoms: fatigue; sore throat; swollen glands on the neck, under the arms, and above the groin; fever that spikes in the late afternoon or early evening (up to 105*F).5 These symptoms can arrive 4 to 8 weeks after infection, usually preceded by a period of general malaise and un-wellness, lasting about a week.1, 5

46. Effects of IM on the Spleen Enlargement of the spleen is a common complication of infectious mononucleosis at some level.5

47. Effects of IM on the Spleen The spleen will enlarge as an abundance of trapped blood cells and macrophages occupy space in the organ stimulating the immune responses as it battles the virus.

48. Effects of IM on the Spleen At this time the spleen is quite fragile in a person with active mono and often is re-situated a little lower than normal due to the enlargement, unprotected by the rib cage, thus making the organ susceptible to injury from blunt trauma in the abdominothoracic region.1

49. Facts Relating to IM However, not everyone will exhibit all of the classic symptoms, and some have minimal symptoms, which can easily go unnoticed, particularly during a traveling sports season. The disease course is usually about 1-3 weeks, although the virus remains active in the saliva for several months, and never completely leaves the body.

50. Uniqueness of Case This case was unique in it’s mechanism and by virtue of the co-morbidity of the Infectious Mononucleosis (complications of enlarged spleen). Splenic injuries are not very common,but it is the most common injured organ when there is an internal injury. Presentation-as spleen injury symptom and signs can vary according to the severity of the injury.

51. Return to Play Criteria Opinions concerning the amount of time to disqualify an athlete from play vary, almost as much as the criteria for the return to play. However a few guidelines concerning the course of IM should be followed for the safety of the athlete. Some of these items of concern are listed as follows:

52. Return to Play Criteria ·        Completion of a 21-day minimum disqualification period from onset of clinical illness or diagnosis. ·        Afebrile state

53. Return to Play Criteria ·        Pharyngitis and lymphadenopathy resolved ·        Liver enzymes have peaked and returned to baseline levels ·        No hepatomegaly by physical examination

54. Return to Play Criteria ·        No splenomegaly by physical exam or ultrasound ·        Labs normal (CBC, asparagine aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) ·        No subjective complaints-fatigue largely resolved, athlete ready to return to play

55. Return to Play Criteria ·        Improvement of strength ·        Any or all complications completely resolved The bottom line is that there is no specific literature or follow up studies that have determined an exact timeline for a safe return to athletics post IM or even post splenic injury. High contact or strenuous sport athletes might have a radiological evaluation, to look at spleen size.15, 16

56. Conclusion Splenic injury or rupture is not an injury that most athletic trainers will see in their career. However, if it is presented, it must be recognized. It is imperative that ATC’s understand the potential mechanisms, symptoms, and signs of splenic injuries. The ATC role is of utmost importance to quickly recognize the probability of internal injury and initiate transport to the nearest emergency facility, as your athlete’s life might depend on it!