Ruptured Spleen

[tchristifulli]

IFT of 63 yr female with a ruptured spleen with approx liter and half of blood in her abdomen. BP 84/42. HR 110. On the 3rd bag of RH negative. Now here's where I get confused... Levophed at 15 mcg/min.... Why in the world would you have Levo going?? You are just making them bleed out faster and increasing oxygen demand. Why would you treat this any different from any other internal bleed? Please educate me.

 

[STXmedic]

1) You want to maintain a perfusing MAP. His current MAP is only 56. 60-65 would be ideal.

2) Levophed has limited beta crossover. Tachyarrhythmias are possible, but less likely than with Epi or Dopamine. Also, MvO2 would be effected less/minimally. If he isn't having cardiac complications, the slight increase in MvO2 wouldn't be too worrisome.

3) Norepinephrine constricts and limits splenic blood flow. If the injury is in the spleen, that could be beneficial to slowing the bleed.

 

[Ewok Jerky]

uh, what he said...

levophed has more Alpha activity than Beta. It will cause vasoconstriction, especially in the small vessels of the spleen (I think they are called sinusoids?). Maybe a little cross over of cardiac activity and tachycardia, but not as much as with epi.

by making the pipes smaller, you increase vascular resistance, increase MAP, and maybe even slow the bleeding through the spleen.

 

[tchristifulli]

That makes sence

 

[tchristifulli]

What do you think about vasopressin ?

 

[STXmedic]

What do you think about vasopressin ?

A good drug for controlling hypotension. Certainly a viable option. It will also lower splenic circulation. I believe it has a more potent effect than NE. Would probably come down to physician preference.

 

[Carlos Danger]

Vasopressin works by a completely different mechanism than the adrenergic agonists (norepi, epi, dopa, phenylephrine), which is why it is useful in settings where the adrenergics are ineffective.

If you goal is just to cause splanchnic vasoconstriction, phenylephrine may be your best bet. I don't know if it's actually ever been shown to cause more gut constriction than the others, but the prevailing wisdom is that it does, which is one of the reasons many don't like to use it in septic shock.

 

[zmedic]

I'd say if someone is bleeding so much from a ruptured spleen that you are starting pressors then it is time to go to the OR. Also I'd wait until the IVC looks like it is full on ultrasound before starting levo, want to make sure they have enough stuff in the pipes before starts pressors.

 

[tchristifulli]

You can tell if the IVC is full on an ultrasound?

 

[chaz90]

You can tell if the IVC is full on an ultrasound?

Sho nuff. You can check the size of the IVC and see how much it collapses on inspiration. This helps evaluate volume status.

 

[Ewok Jerky]

You can tell if the IVC is full on an ultrasound?

You can see a lot on ultrasound. Its really becoming a great diagnostic skill for lots of conditions, whether to rule in or out. Not usually gold standard but can guide treatment while you wait for CT or whatever.

check out this "fast" FAST exam (focused assement with ultrsonography for trauma)
http://youtu.be/kJzdMdsUm0A

 

[EMT B]

Do you think we will start to see any type of ultrasound technology in the field at all?

 

[Farmer2DO]

Levophed has limited beta crossover.

I'm not sure how limited the beta effects are at 15 mcg/min. I've seen plenty of induced tachydysrrhythmias from Levo.

Personally, my choice would be Neo (phenylephrine). All alpha, no beta. And at 63, I don't think this patient needs any more beta stimulation.

What do you think about vasopressin ?

Vasopressin is generally considered a second line, adjunctive pressor. Works on different receptors that the adrenergic agents, so it can be helpful in refractory shock.

I'd say if someone is bleeding so much from a ruptured spleen that you are starting pressors then it is time to go to the OR. Also I'd wait until the IVC looks like it is full on ultrasound before starting levo, want to make sure they have enough stuff in the pipes before starts pressors.

Agree 100%.

If this person is that unstable, my opinion is they probably need surgery at the sending facility.

I'd also want to add FFP and platelets to the PRBCs. Make sure the patient can clot and try and slow the bleeding down.

 

[JPINFV]

Do you think we will start to see any type of ultrasound technology in the field at all?

I think it depends on what else we can find to do with it. Personally I don't see FAST exams being standard in the field for the following reasons:

1. Even if you have a positive FAST scan, the trauma center is still going to do an initial assessment, which is going to include a FAST scan anyways.

2. Given 1, there are three types of trauma patients in terms of FAST scans:
A: Patients going to trauma centers (no benefit in prehospital FAST)
B: Patients who are not going to trauma centers who are FAST negative.
C: Patients not going to trauma centers who are FAST positive (very small population, if any at all).

How many patients are in C?

Thus, I don't see FAST exams as being a good reason to start stocking up on ultrasound company stocks.

 

[medicsb]

Do you think we will start to see any type of ultrasound technology in the field at all?

It is already being prematurely used in a few EMS systems. I don't know of any evidence to show that it actually alters much in terms of prehospital patient care of expediting in-hospital care.

I do think paramedics could be trained to gather ultrasound images and even to interpret some things just as they can for 12 lead ECGs. The question is whether it would make any difference for patient care. Time will tell.

 

[STXmedic]

I'm not sure how limited the beta effects are at 15 mcg/min. I've seen plenty of induced tachydysrrhythmias from Levo.

Personally, my choice would be Neo (phenylephrine). All alpha, no beta. And at 63, I don't think this patient needs any more beta stimulation.

Did some research, and it indeed does have more beta1 stimulation than I thought. Beta2 is very limited, but beta1 can be quite pronounced, especially in higher doses. Thanks for the correction, Farmer

 

[Anjel]

This is all interesting.

There was a discussion on the SPEC Facebook page as well.

https://www.facebook.com/specwi

I know some about Norepinephrine but I want to read up some more about the different types of pressors. If anyone has some resources that they know of, feel free to share.

 

[Carlos Danger]

I want to read up some more about the different types of pressors. If anyone has some resources that they know of, feel free to share.

Here is a good overview: Inotrope & Vasopressor Therapy in Septic Shock

If you PM me your email I can send you a few things.