CASE STUDY

HEMOPERITONEUM SECONDARY TO SPLENIC

INJURY SECONDARY TO BLUNT ABDOMINAL
TRAUMA DUE TO VEHICULAR ACCIDENT

CHRISTINE JOY P. DE CHAVEZ, SN

BSN 2022

MARIBEL A. ESGUERRA, RN, MAN

CLINICAL INSTRUCTOR
 INTRODUCTION

In an age of speed, civil violence, armed conflicts, crimes of passion and traffic

accidents, the incidence of penetrating and blunt injuries to the abdomen has been on the

increase. Trauma is the leading cause of death in persons under 45 years of age, with 10% of

these fatalities attributable to abdominal injury. Blunt abdominal trauma(BAT) is a leading cause

of morbidity and mortality among all age groups. It usually results from motor vehicle collisions,

falls, assaults, sports and recreational accidents. The most commonly injured organs are the

spleen, liver, small bowel, retroperitoneum, bladder, kidneys, diaphragm and pancreas. Clinical

assessment alone in patients with blunt abdominal injury is associated with diagnostic

delays and may sometime lead to missed intra-abdominal injuries due to the neurological

impairment caused by the traumatic event. Also, many injuries may not manifest during the

initial assessment and treatment period.

The surgical exploration of the abdomen, also called an exploratory laparotomy, may

be recommended when there is abdominal disease from an unknown cause (to diagnose), or

trauma to the abdomen (gunshot or stab-wounds, or "blunt trauma"). It is one of the most

commonly performed surgical procedures to determine abdominal injuries. Most patients with

penetrating abdominal injuries will also require laparotomy given the high incidence of intra-

abdominal injury once the fascia has been violated. The main indications for exploration of the

abdomen following blunt trauma are peritonitis, unexplained hypovolemia, hemoperitoneum

findings after FAST or DPL examinations, and the presence of other injuries known to be

frequently associated with intra-abdominal injuries.

Accordingly, hemoperitoneum is the presence of blood in the peritoneal cavity. It is

generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to

identify and control the source of the bleeding. Evacuation of hemoperitoeum is the evacuation

of fluids from the abdomen it is included in any abdominal surgical procedure. When you have

this condition, blood is accumulating in your peritoneal cavity. Blood in this part of your body
can appear because of physical trauma, or a ruptured blood vessel and organ. In the

hemodynamically unstable patient, a rapid evaluation for hemoperitoneum can be accomplished

by means of diagnostic peritoneal lavage (DPL) or the focused assessment with sonography for

trauma (FAST). Hemoperitoneum may present with no signs except hypovolemia. The abdomen

may be flat and nontender. Patients whose extra-abdominal bleeding has been controlled should

respond to initial fluid resuscitation with an adequate urine output and stabilization of vital signs.

If hypovolemia recurs, intra-abdominal bleeding must be considered to be the cause.

Splenorrhaphy is performed in selected cases of splenic injury, when splenic preservation

is desired. It should be attempted in all patients except when the spleen is shattered, or avulsed

and in multiple concomitant injuries where splenectomy is advised. Spleens that have been

injured and are bleeding require this procedure. Most commonly these injuries are from car or

bike accidents, falls, kicks, etc. The cracks in the spleen, which cause the bleeding, are repaired

using sutures. Frequently this doesn’t completely stop the bleeding and additional techniques

must be used including blood-clotting agents applied to the bleeding areas, mesh wrapped around

the spleen to hold it together or removal of small fragments of the spleen.

 PATIENT’S PROFILE

Name: PATIENT A Gender: Male

Civil Status: Married Age: 44 years old

Birth date: May 20, 1974 Occupation: Mami and Goto vendor

Address: PANSOL, CALAMBA LAGUNA

Birth place: Biliran, leyte

Nationality: Filipino

Number of children: 2

Date of Admission: September 13, 2018 9:45 am

Admitting Diagnosis: Acute abdomen secondary to blunt abdominal injury

Operation performed: Exploratory Laparotomy, Splenorrhapy, Evacuation of hemoperitoneum

Date of operation: September 13, 2018, 10:30am

Attending Physician: Dr. JS

Hospital: Batangas Medical Center, female surgical ward

Final diagnosis: Hemoperitoneum secondary to splenic injury secondary to blunt abdominal

trauma due to vehicular accident.

CLINICAL APPRAISAL

The patient is known to be habitual alcohol drinker and smoker. However, he did not

have any significant diseases or illnesses in the past which lead him to the hospital. He only

experienced cough, colds and fever. Whenever he is sick, he will just drink over the counter

medications. The patient also has no history of any kind of allergies.

The patient is working as goto and mami vendor. He is using a side car as means of

transportation. He is a habitual drinker. Last September 13, at around 3am, he left his house to

sell his goods . By 4am, he was invited by his friends to drink alcoholic beverages. Being a

habitual drinker, he did not reject the invitation. In going home and under the influence of

alcohol he did not notice that he will be taking a steep road , unable to control the breaks of his

side car leading to accident. He collided with a wall. The goto and mami had spilled which
causes scald burns on his upper and lower extremities. He got admitted directly to Batangas

Medical Center with Acute abdomen secondary to blunt abdominal injury as admitting diagnosis.

History of Present Illness

His final diagnosis is hemoperitoneum secondary to splenic injury secondary to blunt

abdominal trauma due to vehicular accident. He also has a scald burns on his upper and

lower extremities

History of Past Illness

He experienced cough, cold and fever at times but denies of other illnesses.

Family health history

There is no known family health history.

PHYSICAL ASSESSMENT

Body Area Method of Findings Analysis Significance

Assessment
Vital Signs Inspection BP: 90/60 Abnormal RR It indicates that
mmHg the patient has a
PR: 89 bpm problem on
RR: 28 cpm respiration
Temp: 36.8 ̊ C
General Inspection Medium body Abnormal Weakness and
Appearance frame with limited ROM
brown indicates
complexion patient is need
Weak, for monitoring
conscious,
cooperative,
coherent
Limited ROM
Skin Inspection Scald burns on Abnormal It aids the
upper right arm healing process
extended to by providing a
axilla with moist,
yellowish nourishing
discharge environment for
the skin to
repair.
Nose Inspection With NGT Normal It indicates the
connected to normal gastric
 bed side bag drainage due to
draining to the presence of
greenish gastric bile.
content
Abdomen Inspection and With Abnormal It is effective
Palpation paramedian way to close
incision, staple wounds
wire, dry and
intact
Lower Inspection With IVF Abnormal The IVF
extremities D5LR 1L at indicates that
650 cc level, the patient
KVO rate, needs hydration
hooked at the
left saphenous
vein, infusing
well
Genitalia Inspection With foley Abnormal Foley catheter
catheter was inserted
connected to because the
bed side bag patient is under
draining to 300 the 24h urine
cc yellowish albumin
urine output collection to
determine
albumin content
in the urine

ANATOMY AND PHYSIOLOGY

OF ABDOMEN
 The abdomen constitutes the part of the body between the thorax and pelvis, in humans

and other vertebrates. The region enclosed by the abdomen is termed the abdominal cavity. Also,

abdomen stretches from the thorax at the thoracic diaphragm to the pelvis at the pelvic brim.

 The boundary of the abdominal cavity is the abdominal wall in the front and the

peritoneal surface at the rear.

 The abdomen contains most of the tubelike organs of the digestive tract, as well

as several solid organs.

 The entire abdominal region is comprised of both solid and hollow organs.

 Solid organs – spleen, liver, pancreas

 Hollow organs – stomach, intestines, bladder and gallbladder

 Solid organs typically bleed when they are injured, while hollow organs tend to

spill their contents into the abdominal cavity when injured

 Spleen - A highly vascular, ductless organ that is located in the left abdominal

region near the stomach or intestine and is concerned with final destruction of red

blood cells, filtration and storage of blood, and production of lymphocytes

 The abdominal wall and the abdominal organs are both surrounded by a

membrane called the peritoneum.

 There is a separate thin membrane that surrounds all the organs in the abdomen,

enclosing all the organs in a bag-like membrane. This membrane is called the

visceral peritoneum.

 The peritoneal cavity is the space between the peritoneum of the abdominal wall

and abdominal organs.

 The peritoneal cavity contains the liver, spleen, bowel, stomach, and mesentery

PATHOPHYSIOLOGY

Hemoperitoneum

Modifiable Risk Factor

 Alcohol drinker

 Steep road

 Vehicular accident

Collisions between injured person and external environment

Rapid deceleration forces

Forces acting on the person’s internal orggans

 DIAGNOSTIC AND LABORATORY RESULTS

CHEST PA

(September 13, 2018)

The chest x-ray is the most common radiological investigation in the emergency

department. The PA view is frequently used to aid in diagnosing a range of acute and chronic

conditions involving all organs of the thoracic cavity. Additionally, it serves as the most sensitive

plain radiograph for the detection of free intraperitoneal gas or pneumoperitoneum in patients

with acute abdominal pain.

IMPRESSION:

Pulmonary contusion with hemothorax, left

Multiple ribs and clavicular fractures, left

Subcutaneous emphysema, left lateral chest wall

CHEST PA/LATERAL

(September 16, 2018)

IMPRESSION:

Follow up study since September 15, 2018 shows partial regression of pleural fluid in the left

hemithorax.

The rest of the findings are unchanged.

 Focused Abdominal Sonography Test (FAST) Ultrasound

The FAST exam evaluates the pericardium and three potential spaces within the peritoneal cavity

for pathologic fluid. It is an ultrasound protocol developed to assess for hemoperitoneum and

hemopericardium.

FINDINGS:

Fluid collection is noted in the hepatorenal, splenorenal angles and pelvic region

Gas shadows obscures in the area of interest (pericardium). Consider subcutaneous emphysema

HEMATOLOGY

RESULT
PRE-OP (before POST OP (after
TEST NORMAL SIGNIFICANCE
transfusion) transfusion)
RANGE
RBC COUNT 3.1 x 10^6/uL 5.1 x 10^6/uL 4.7-6.1 Normal
HEMOGLOBIN 10.2 g/dL 12.2 g/dL 13.5-17.5 Mild Anemia
HEMATOCRIT 34 % 40 % 41-50 Normal
WBC COUNT 5,800 /uL 6,000 /uL 5,000-10,000 Normal

CLINICAL CHEMISTRY

TEST RESULT NORMAL RANGE SIGNIFICANCE

Blood Urea Nitrogen 13 mg/dl 7-20 Normal
Creatinine 0.8 mg/dl 0.6-1.2 Normal
Sodium 145 mmol/L 136-145 Normal
Potassium 4.5 mmol/L 3.6-5.2 Normal
 DRUG STUDY

DOSE / ROUTE ADVERSE NURSING

DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: It is used to treat a Contraindicated in Dose: 250 mg CNS: drowsiness,  Arrange for culture and
Ciprofloxacin variety of bacterial hypersensitivity, headache, sensitivity tests before
infections. It works cross-sensitivity Route: IV dizziness, tremor beginning therapy.
Brand Name: by stopping the among agents may
Cipro, growth of bacteria. occur. Use Frequency: q8 GI:  Dilute drug using D5W
Cipro XR, It will not work for cautiously in nausea, vomiting, or o.9% NaCl for
ProQuin XR virus infections underlying CNS abdominal pain, injection to a final
(such as common pathology, renal constipation, concentration of 1 to
CLASSIFICATI cold, flu). impairment, diarrhea 2mg/ml before use.
ON Unnecessary use or cirrhosis. Infuse slowly.
Fluoroquinolones overuse of any GU:
antibiotic can lead interstitial cystitis,  Know that long-term
to its decreased vaginitis therapy may result in
effectiveness. overgrowth of
Skin: rash organisms’ resistant to
ciprofloxacin.
Other:
thrombophlebitis,  Advise patient that
burning, pruritus, hypersensitivity
erythema, edema reactions may occur
even after first dose. If
rash occur, notify the
physician
DOSE / ROUTE ADVERSE NURSING
DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: It is used for the Contraindicated in Dose: 500 mg CNS: headache,  Observe the 10 R’s
Metronidazole treatment of patients with dizziness before giving the drug.
 serious infection hypersensitivity to Route: IV
Brand Name: caused by drug or other CV: edema  Assess patient for
Flagyl susceptible nitroimidazole Frequency: q6 infection and skin for
anaerobic bacteria derivatives. Also, GI: severity areas of local
in intra-abdominal blood dyscrasia and nausea, vomiting, adverse reactions
CLASSIFICATI infections and for active CNS disease. abdominal
ON: both pre and post- cramping or pain,  Record number and
Antibiotic operative diarrhea, character of stools
prophylaxis constipation, dry
mouth  Assess pt.’s and
family’s knowledge of
GU: darkened drug therapy
urine, polyuria,
dysuria  Inform patient that
medication may cause
Respiratory: upper an unpleasant metallic
respiratory taste.
infection
 Inform patient that
Skin: flushed skin, medication may cause
rash urine to turn dark

DOSE / ROUTE ADVERSE NURSING

DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: It is used to relieve Contraindicated in Dose: 100 mg CNS: dizziness,  Assess for level of
Tramadol HCL moderate to patients with headache, anxiety pain relief and
moderately severe hypersensitivity to Route: IV administer prn dose
Brand Name: pain. It works in the drug or with acute CV: vasodilation
Ultram brain to change how intoxication from Frequency: q8  Monitor vital signs
your body feels and alcohol, hypnotics, EENT: and assess for
CLASSIFICAT responds to pain. centrally acting visual disturbances orthostatic
ION analgesics, opioids, hypotension or signs
Analgesic or psychotropic GI:
drugs. nausea, vomiting, of CNS depression.
dry mouth,
abdominal pain,  Discontinue drug and
constipation, notify physician if
diarrhea S&S of
hypersensitivity
GU: urine retention occur.

Skin: pruritus,  Assess bowel and

diaphoresis, rash bladder function;
report urinary
frequency or
retention.

 Monitor ambulation
and take appropriate
safety precautions.

DOSE / ROUTE ADVERSE NURSING

DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: Short-term Contraindicated in Dose: 30 mg CNS: drowsiness,  Assess first the
Ketorolac management of patients with headache, patient before
moderately severe, hypersensitivity to Route: IV dizziness administering the
Brand Name: acute pain requiring drug, with active drug
Toradol opioid-level peptic ulcer disease, Frequency: q8 for CV: edema,
analgesia. recent GI bleeding or 3 doses hypertension,  Correct hypovolemia
It is usually used perforation, palpitations, prior to
CLASSIFICAT before or after advanced renal administration of
ION medical procedures impairment, risk for GI: ketorolac.
Non-steroidal or after surgery. renal impairment nausea, vomiting,
anti- due to volume abdominal pain,  Protect drug vials
inflammatory depletion, suspected constipation, from light.
drug (NSAID) or confirmed diarrhea
cerebrovascular  Monitor urine output
bleeding, incomplete GU: acute renal
hemostasis, or high failure  Monitor for S&S of
risk of bleeding. GI distress or
Hematologic: bleeding including
decreased platelet, nausea, GI pain,
thrombocytopenia diarrhea, melena, or
hematemesis.

 Monitor for fluid

retention and edema
DOSE / ROUTE ADVERSE NURSING
DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: Prevention and Contraindicated in Dose: 1% cream Hematologic:  Use sterile application
Silver treatment of wound patients with leukopenia technique to prevent
sulfadiazine sepsis in patients hypersensitivity to Route: Topical wound infections
with second and drug or any of the Skin: pain, burning,
Brand Name: third-degree burns. other ingredients in Frequency: pruritus, skin  Use drug only on
Silvadene It helps to prevent or the preparation. applied on necrosis, rash, affected areas. Keep
Thermazene treat serious Drug may increase affected area BID erythema these areas medicated
Flamazine infection. possibility of multiforme, skin at all times
kernicterus. discoloration
 Bathe patient daily, if
CLASSIFICAT possible.
ION
Anti-microbial  Inspect pt’s skin
daily, and note any
changes. Notify
prescriber if burning
or excessive pain
 develops

 Tell prescriber if
hepatic or renal
dysfunction occurs;
drug may need to be
stopped.
DOSE / ROUTE ADVERSE NURSING
DRUG INDICATION CONTRAINDICA and REACTION RESPONSIBILITIES
TION FREQUENCY
Generic Name: It is indicated as an This solution should Dose: 500cc CV: chest  Consider the 10 R’s of
Amino acid amino acid source in not be used in discomfort, administering
parenteral nutrition patients in hepatic Route: IV palpitations, medication
Brand Name: regimens. This coma, severe renal
Aminosyn II completely utilizable failure, metabolic Frequency: q12 GI:  Monitor for signs and
substrate promotes disorders involving for 2 doses nausea, vomiting, symptoms of
protein synthesis impaired nitrogen Skin: flushing hepatoxicity
CLASSIFICAT and wound healing utilization or Other: Chills,
ION and reduces the rate hypersensitivity to fever, headache  Assess patient
Parenteral, of protein one or more amino condition before
Nutritional catabolism. acids. starting the therapy
products
 Be alert to adverse
reaction

 Monitor patient
temperature

 If GI reaction occur
monitor patient
hydration
Nursing Care Plan
 PROGNOSIS

Patient’s condition is eventually improving 3 days after surgery. After undergone

treatment such as exploratory laparotomy, splenorrhaphy, and evacuation of hemoperitonuem.

His blood pressure level has a progress from 80/50 mmHg to 90/60 mmHg. Patient’s laboratory

tests were repeated and the rest of the findings are unchanged except to the Chest PA which

shows partial regression. Since the patient is post-operative and having NGT tube, chest tube

thoracostomy he is prone for infections and needs proper care until he is fully recovered.

However, he was given prescribed antibiotics as to prevent and treat infection.

PROPOSED ACTIONS AND RECOMMENDTIONS

Patient A must continue monitoring for possible complication and infections. He must

follow prescribed medication to prevent infection and other complication of diseases. Also, the

patient goal of therapy is for the maintenance and restoration of oxygen‐carrying capacity and

arrest of hemorrhage. Hemoperitoneum can be life-threatening if could not seek immediately

medical treatment. Furthermore, reduction of stress and provide adequate rest is also

recommended in order to help them in his recovery. Health teaching to patient and family is very

necessary to make the patient able to return in a normal life.

BIBLIOGRAPHY

Nursing Care Plan :

Nurse’s Pocket Guide Edition 13 th (Doenges, Moorhouse & Murr)

Drug Study:

Nursing 2007 Drug Handbook 27 th Edition, Lippincott Williams &Wilkin

Nurse’s Drug Handbook 10 th Edition, Jones & Bartllet

https://www.rxlist.com/consumer_ciprofloxacin_cipro/drugs-condition.htm

https://www.statpearls.com/ArticleLibrary/viewarticle/19562

https://rnspeak.com/metronidazole-drug-study/

https://www.rxlist.com/consumer_metronidazole_flagyl/drugs-condition.htm

https://www.webmd.com/drugs/2/drug-4398-5239/tramadol-oral/tramadol-oral/details

http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/T063.html

https://www.empr.com/drug/ketorolac-iv-im/

http://robholland.com/Nursing/Drug_Guide/data/monographframes/K005.html

https://www.mayoclinic.org/drugs-supplements/silver-sulfadiazine-topical-route/proper-
use/

https://www.scribd.com/doc/106417902/Drug-Study

https://www.drugs.com/pro/amino-acids-injection.html

https://www.rxlist.com/aminosyn-ii-injection-drug.htm#dosage

https://www.scribd.com/document/232849252/Blunt-Abdominal-Trauma
https://medlineplus.gov/ency/presentations/100049_2.html

https://1library.net/document/nzw4ovqe-study-computed-tomography-evaluation-blunt-

abdominal-injury.html

https://www.intechopen.com/books/trauma-surgery/abdominal-trauma

https://findanyanswer.com/what-is-the-cpt-code-for-evacuation-of-hemoperitoneum

https://www.evergreenhealth.com/splenorrhaphy

https://pubmed.ncbi.nlm.nih.gov/7604621/

https://nursece4less.com/Tests/Materials/N087EMaterials.pdf

https://study.com/academy/lesson/hemoperitoneum-signs-symptoms.html

https://healthjade.net/hemoperitoneum/

https://www.slideshare.net/sampurnadas3133/abdominal-injury-60576940

https://www.slideshare.net/djorgenmorris/ch11-abdominal

https://free-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-risk-for.html