What is the false statement regarding a 22-year-old female patient with a Glasgow Coma Scale (GCS) score of 10, an 8-centimeter spleen lesion with subscapular subcapsular hematoma, hypotension, and tachycardia, who has fallen from a motorcycle: A) the patient can be followed up without emergent operation, B) there is intermediate brain damage, or C) the patient is hemodynamically stable?

Management of a 22-Year-Old Female Motorcycle Trauma Patient

Statement C, "the patient is hemodynamically stable," is false. With a blood pressure of 110/55 mmHg and heart rate of 100 beats per minute, this patient shows signs of early hemodynamic instability that requires immediate intervention.

Patient Assessment

• The patient presents with multiple concerning findings:
  • Glasgow Coma Scale (GCS) score of 10, indicating moderate brain injury 1
  • 8 cm splenic lesion with subcapsular hematoma, suggesting a grade 2-3 splenic injury 1
  • Tachycardia (100 bpm) with borderline blood pressure (110/55 mmHg), suggesting early compensatory response to blood loss 1

Hemodynamic Status Analysis

• According to WSES guidelines, hemodynamic instability is defined as:

  • Systolic BP < 90 mmHg with evidence of skin vasoconstriction, altered level of consciousness, or shortness of breath, OR
  • BP > 90 mmHg but requiring fluid boluses/transfusions and/or vasopressors, OR
  • Base excess > -5 mmol/l, OR
  • Shock index > 1, OR
  • Transfusion requirement of at least 4-6 units of packed RBCs within 24 hours 1

• This patient has:

  • Tachycardia (100 bpm) with systolic BP of 110 mmHg
  • Shock index of 0.91 (heart rate/systolic BP = 100/110), approaching the critical threshold of 1.0 1
  • Altered mental status (GCS 10)
  • These findings together indicate early compensatory shock 1

Brain Injury Assessment

• GCS score of 10 indicates moderate brain injury 1
• This level of brain injury requires careful monitoring and management to prevent secondary brain injury 1
• The combination of splenic injury and brain trauma requires special consideration, as hypotension from splenic bleeding can worsen secondary brain injury 2

Splenic Injury Management

• The 8 cm splenic lesion with subcapsular hematoma likely represents a grade 2-3 splenic injury according to the AAST classification 1

• In a polytrauma patient with both splenic and brain injuries, immediate operative management is indicated when 3:

  • The patient shows signs of hemodynamic instability
  • There is risk of secondary brain injury from hypotension
  • The patient requires prolonged transport or monitoring is limited

• The World Journal of Emergency Surgery guidelines recommend operative management in patients with splenic injuries and concomitant brain injuries, particularly when the patient shows signs of hemodynamic compromise 1, 3

Correct Answer Analysis

• Statement A (patient can be followed up without emergent operation): False - With hemodynamic instability, brain injury, and significant splenic trauma, emergent operation is indicated 1, 3
• Statement B (intermediate brain damage): True - GCS of 10 indicates moderate brain injury 1
• Statement C (patient is hemodynamically stable): False - Tachycardia with borderline blood pressure indicates early compensatory shock 1
• Statement D (grade of splenic injury is 2-3): True - An 8 cm lesion with subcapsular hematoma is consistent with grade 2-3 injury 1
• Statement E (polytrauma patient): True - The combination of significant splenic injury and brain trauma constitutes polytrauma 1

Management Recommendations

• Immediate surgical intervention is indicated due to:

  • Signs of hemodynamic compromise 1
  • Significant splenic injury with subcapsular hematoma 1
  • Concomitant brain injury that could be worsened by ongoing blood loss 2
  • Risk of delayed splenic rupture if managed non-operatively 3

• Operative management should aim for splenic preservation when possible, but splenectomy may be necessary if bleeding cannot be controlled 1, 3

• Careful monitoring of neurological status and prevention of secondary brain injury is essential 1, 2