What is the likely diagnosis for a patient with left upper hypochondriac pain after a motor vehicle accident (MVA)?

Splenic Injury

In a patient presenting with left upper hypochondriac pain after a motor vehicle accident, the most likely diagnosis is splenic injury, which is the most commonly injured viscus in blunt abdominal trauma. 1, 2

Clinical Presentation and Mechanism

• The spleen is the most frequently damaged organ in blunt abdominal trauma and represents the most likely source of serious injury in MVA victims 2
• Motor vehicle crashes are the leading mechanism causing splenic trauma, with the elastic rib cage transmitting force directly into the abdominal compartment 1
• Left upper quadrant pain is the classic presenting symptom, often associated with referred left shoulder pain (Kehr's sign) in adolescents and adults 1
• The front seat position in an MVA creates significant risk for splenic injury due to deceleration forces and potential seat belt compression across the upper abdomen 3

Immediate Assessment Priorities

Hemodynamic status determines the entire management pathway and must be assessed immediately. 1, 3

• Check for signs of hemorrhagic shock: hypotension (systolic BP <90 mmHg), tachycardia (HR >100), altered mental status, or decreased urine output 1, 2
• Patients with Class III hemorrhagic shock (1,500-2,000 mL blood loss, representing 30-40% blood volume) present with systolic BP 90-100 mmHg, heart rate 110-120, and decreased urine output 1
• If the patient is hemodynamically unstable with suspected intra-abdominal injury, proceed directly to trauma laparotomy without delay for additional imaging 3
• Every 3 minutes spent in the emergency department increases death probability by 1% in hemodynamically unstable trauma patients 3

Diagnostic Approach in Stable Patients

For hemodynamically stable patients, contrast-enhanced CT scan is the gold standard for diagnosing splenic trauma. 1

• Perform FAST (Focused Assessment with Sonography for Trauma) as the initial rapid bedside assessment to detect free intraperitoneal fluid 1
• FAST has high specificity (0.97-1.0) but lower sensitivity (0.56-0.71) for detecting intra-abdominal injuries 1
• A positive FAST with significant free fluid in a hemodynamically unstable patient mandates urgent surgery without CT 1, 3
• In stable patients with positive FAST or high clinical suspicion, proceed to contrast-enhanced CT for definitive diagnosis and injury grading 1

Critical Pitfalls to Avoid

• Never assume normal initial hemoglobin excludes significant hemorrhage—acute bleeding may not immediately reflect in hemoglobin levels due to lack of hemodilution 3
• Do not be falsely reassured by the absence of peritoneal signs; splenic injuries can present with isolated left upper quadrant tenderness without generalized peritonitis 4, 2
• Do not delay laparotomy for CT imaging in hemodynamically unstable patients, as this significantly increases mortality 3
• Recognize that splenic injury can present with delayed rupture—some patients may initially appear stable but deteriorate hours to days later 5
• Be aware that elderly patients may have atypical presentations with decreased physiologic reserve and higher mortality risk 1

Management Based on Hemodynamic Status

Hemodynamically stable patients: Non-operative management (NOM) is the mainstay for stable adult patients with splenic trauma, with success rates of 70% in appropriately selected cases 1, 6, 2

Hemodynamically unstable patients: Immediate surgical intervention with splenectomy is required for patients who remain hypotensive despite fluid resuscitation (three boluses of 20 mL/kg crystalloid) 1, 3

• Patients requiring blood transfusion in the emergency department are likely to need operative management 2
• Multiple injuries, abnormal hematocrit (<30%), or coagulopathy (PT >14 seconds) identify patients requiring urgent operative therapy 2