Splenic Rupture Manifesting Two Years after Diagnosis of Injury

The entity of delayed splenic rupture is often challenged. This case report describes a patient who presented with splenic rupture 2 years after a prior splenic injury from blunt trauma. The pathology report confirmed previous splenic injury. Delayed splenic rupture is possible for extended periods following splenic injury managed conservatively.     

An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature

A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. Placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.     

外伤性脾破裂80例诊治分析

目的：探讨外伤性脾破裂的诊断和外科治疗原则。方法：回顾分析2004年1月—2010年1月收治的80例外伤性脾破裂患者的临床资料进行。结果：结合病史、腹腔穿刺、腹部B超或CT检查结果,所有患者均获得及时诊断。手术治疗74例,其中脾切除42例（52.5%）,保脾手术32例（40%）,非手术治疗6例（7.5%）。所有病例均治愈。结论：及时诊断是治疗的前提,脾切除术是首选的手术,选择合适的患者行保脾手术或者非手术治疗是安全、有效的。     

创伤性脾破裂保留脾脏治疗57例分析

目的 探讨创伤性脾破裂保脾方法和疗效.方法 分析2001年1月至2011年1月采取保脾治疗57例创伤性脾破裂:非手术治疗6 例,单纯缝合修补7例,用结缔组织片缝合修补13例,脾部分切除3例,脾脏切除合并自体脾脏片大网膜移植28例.结果 治愈56例,1例死于合并腹膜后血肿及慢性肝病,其中4例并发脾切除热,平均住院时间11.7 d.结论 根据脾损伤的程度和患者全身情况,选择适宜的保留脾脏治疗方法既保留脾脏功能,又能安全有效地抢救生命,减少并发症,降低病死率.     

非手术治疗脾破裂的临床分析

目的:探讨非手术治疗脾破裂的选择标准和监测指标。方法:回顾性分析本院2001年10月至2005年9月非手术治疗脾破裂42例病人的临床资料。结果:37例病人痊愈出院,无任何后遗症;5例病人因继续出血或延迟出血或并发症而转为手术治疗。结论:严格选择非手术治疗脾破裂标准,严密监测指标,合理治疗有效。     

Enoxaparin-induced alopecia in patients with cerebral venous thrombosis

OBJECTIVE: To report three cases of alopecia induced by the anticoagulant enoxaparin in cerebral venous thrombosis (CVT) patients. CASE SUMMARY: Three female patients were treated initially with direct intrasinus urokinase, and then followed by low-molecular-weight heparin (LMWH) enoxaparin at 1 mg/kg given subcutaneously twice daily for 3 weeks. It was switched to oral anticoagulant warfarin at 5 mg daily for another 6 months. Nearly 3 weeks after the initiation of anticoagulation, all of the three patients complained of excessive hair loss with large areas of patchy, non-scarring alopecia. Hair growth returned to normal within 1 month after the completion of enoxaparin. DISCUSSION: Unfractionated heparin remains the first-line treatment of CVT because of its efficacy, safety and feasibility. Alopecia has been reported as a side effect of LMWHs dalteparin and tinzaparin. The pattern of hair loss, telogen effluvium, involves the induction of the hair follicle into a resting phase without apparent pathologic implication. In addition, this article also reviewed other medications taken by the patients that are possibly associated with hair loss. CONCLUSION: From the review of literature, there is no report of alopecia caused by urokinase. Using the Naranjo ADR Probability Scale, a score of 6 suggests that enoxaparin was the probable cause of alopecia in our three patients. This report introduces evidence of alopecia as a probable side effect of enoxaparin, but stresses the efficacy and safety of LMWH. As this is not a life-threatening disorder, we hope to increase the awareness of pharmacists and clinicians to this relatively rare but important side effect.     

Contrast-enhanced sonography for differential diagnosis of an inhomogeneous spleen of unknown cause in patients with pain in the left upper quadrant.

OBJECTIVE: Second-generation contrast agents have shown spleen-specific uptake. The aim of this study was to investigate the ability of contrast-enhanced sonography (CES) to demarcate splenic lesions in patients with pain in the left upper quadrant (LUQ) and an inhomogeneous splenic texture. METHODS: From October 2003 to July 2005, 31 consecutive patients with pain in the LUQ and splenic inhomogeneity on B-mode sonography were studied by CES using a second-generation contrast agent (SonoVue; Bracco SpA, Milan, Italy). The following data were retrospectively evaluated: extent of enhancement (EE) of the spleen and focal splenic lesions was determined and classified, with the EE of surrounding tissue used as an in vivo reference. Focal splenic lesions were classified after CES as round or wedge shaped, solitary or multiple, and anechoic, hypoechoic, or hyperechoic. RESULTS: The EE of the spleen after CES was anechoic (n = 1), hypoechoic (n = 1), or hyperechoic (n = 29). In 16 of 31 patients, focal lesions were seen after CES. The EE of the lesions was anechoic (n = 11) or hypoechoic (n = 5). Lesions were solitary (n = 6) or multiple (n = 10) and round (n = 5) or wedge shaped (n = 11). Final clinical diagnoses of splenic abnormalities were no specific diagnosis (n = 13), complete autosplenectomy (n = 2), splenic lymphoma (n = 5), and splenic infarction (n = 11). The CES diagnoses were confirmed by computed tomography (n = 21), scintigraphy (n = 2), magnetic resonance imaging (n = 1), and clinical follow-up (n = 7). CONCLUSIONS: In patients with pain in the LUQ and splenic inhomogeneity, CES enables visualization of splenic abnormalities in more than 50% of the patients; in this group, splenic infarction was the most common diagnosis.     

Administration of enoxaparin by continuous infusion in a naturalistic setting: analysis of renal function and safety

STUDY OBJECTIVE: To describe the clinical use and safety of continuous infusion (CI) enoxaparin in a naturalistic setting and to evaluate the influence of renal function on enoxaparin elimination. DESIGN: Retrospective medical record review. SETTING: 1000-bed tertiary care teaching centre. PATIENTS: Hospitalized patients that received enoxaparin by CI during a 2-year period. INTERVENTIONS: None. MEASUREMENTS: Specific details of dosage and monitoring were collected. Adverse drug reactions (ADR) were recorded. Creatinine clearance (CrCl) was calculated using Cockroft and Gault and Brater equations. A population pharmacokinetic analysis was performed using the non-linear mixed effect model (NONMEM). For patients located in the intensive care unit (ICU) and ward, POSTHOC pharmacokinetic parameter estimates were evaluated using the Wilcoxon rank-sum. Pearson correlation coefficient was calculated to determine the association between renal function and anti-Xa clearance. MAIN RESULTS: Sixty-seven patients received enoxaparin by CI of which 61.2% were in the ward and 38.8% in the ICU. The average initial rate and duration of infusion were 5.2 mg/h and 5.6 days, respectively. The number of anti-Xa concentration measurements averaged five per patient. Nine patients experienced an ADR. The most frequent ADR was gastrointestinal bleeding (n = 4). Among the 67 patients, 48 had available anti-Xa concentrations and were included in the NONMEM model. The anti-Xa CL and volume of distribution for ICU and ward patients averaged 0.64 +/- 0.34 L/h, 10.6 +/- 1.55 L and 1.01 +/- 0.39 L/h, 9.08 +/- 1.17 L, respectively. CrCl was not a significant covariate when included in the NONMEM model, and the association between CrCl and anti-Xa clearance was not significant (R2 = 0.0005; P = 0.8916). CONCLUSIONS: This study is the first to report the use and safety of prolonged CI enoxaparin. Pharmacokinetic parameters of enoxaparin differ in ICU vs. ward patients. Overall, we found the safety of CI to be comparable to subcutaneous administration. Also, we found no effect of renal function on enoxaparin elimination.     

Comparison of enoxaparin and unfractionated heparin in endovascular interventions for the treatment of peripheral arterial occlusive disease: a randomized controlled trial

Summary. Background: Although unfractionated heparin (UFH) is an effective antithrombotic agent in endovascular interventions for the treatment of peripheral occlusive arterial disease (PAOD), it produces a highly variable anticoagulant response. Intravenous (i.v.) enoxaparin might be an effective and safe alternative. Patients and methods: In a prospective, open‐label, randomized, single‐center trial, 210 patients with PAOD (Fontaine stage IIb to IV) were randomly assigned in a 1 (UFH): 2 (enoxaparin) fashion to receive an i.v. bolus of 60 units UFH per kg body weight or 0.5 mg enoxaparin per kg body weight, respectively, before endovascular intervention. The primary composite endpoint assessed the clinical performance of enoxaparin by comparing the peri‐interventional rate of thromboembolia/occlusion (efficacy) of endovascularly reconstructed areas, of bleeding according to the Global Utilization of Streptokinase and t‐PA for Occluded Coronary Arteries (GUSTO) criteria (safety) and of any necessary re‐intervention for any percutaneous transluminal angioplasty (PTA)‐related bleeding. The secondary endpoint evaluated anti‐factor (F)Xa levels during intervention. Results: The primary composite endpoint showed a better performance of enoxaparin (10.5% vs. 2.5% absolute difference – 8.0%; P < 0.05). The concomitant use of acetylsalicylic acid (ASA) significantly (P < 0.05) increased the risk of a complication in the UFH group, but not in the enoxaparin group. Within 15 min, anti‐Xa levels were reached by 63.7% of patients treated with enoxaparin and only by 39.1% with UFH. Conclusion: Enoxaparin has a better performance than UFH in endovascular interventions for the treatment of PAOD. In patients with concomitant use of ASA, the risk of complications with UFH increases significantly compared with enoxaparin.     

外伤性脾破裂96例临床分析

目的探讨外伤性脾破裂的诊断与治疗经验,提高救治水平。方法回顾性分析九龙坡区第一人民医院1996年1月至2008年12月收治的96例外伤性脾破裂患者的临床资料。结果非手术治疗11例全部治愈;手术组80例,治愈78例,死亡2例;术后未发生脾切除后凶险感染等严重并发症。结论外伤性脾破裂的治疗应根据患者个体情况及脾破裂的类型而定。手术仍是治疗脾损伤的主要方法 ,非手术治疗应严格掌握适应证。     

创伤性脾破裂保脾手术探讨(附86例报告)

目的：探讨创伤性脾破裂保脾手术的各种方法及意义。方法：回顾性分析86例创伤性脾破裂保脾手术的临床资料。结果：单纯脾缝合术32例，单纯脾捆扎术6例，脾部分切除术25例，脾网扎术6例，脾动脉结扎术17例，全部康复，结论：脾破裂后保留脾脏手术应根据术中伤脾情况选择不同手术方式。儿童患者应尽力设法保留脾脏，老年患者从严掌握。同时注意要按照抢救生命第一，保留器官第二原则。     

Comparison of different dose regimens of enoxaparin in deep vein thrombosis therapy in pregnancy

INTRODUCTION: Pregnant women have a higher risk of developing deep vein thrombosis (DVT) and consequent thrombogenic events, including pulmonary embolisms. Low-molecular-weight heparin (LMWH) products have been shown to successfully treat DVT with few significant side effects. The purpose of this study was to compare the effects of two dose regimens of enoxaparin (a LMWH) in the management of DVT in pregnancy. METHODS: A total of 35 pregnant patients with DVT were enrolled in this study. As first-line anticoagulation therapy, patients were administered an intravenous unfractionated heparin infusion for 5 days, followed by a subcutaneous injection of enoxaparin 1 mg/kg twice a day until discharge. The enoxaparin therapy continued at home with 1 mg/kg twice a day for 18 patients (group I) and 1.5 mg/kg once a day for the other 17 patients (group II). Enoxaparin was discontinued 12-24 hours before delivery and restarted within 8-12 hours after delivery. Warfarin was given as adjuvant therapy along with enoxaparin in the post-partum period. Enoxaparin was discontinued when an international normalised ratio of 2 or above was reached. Differences between the two groups in terms of therapy response, complications and efficacy were recorded. RESULTS: Thrombophilic disease was observed in three patients in each group. The iliac vein had the highest incidence of DVT in both groups. During therapy, two patients in group I were diagnosed with a mild haemorrhage; one patient (in group II) had abortion. There were no significant differences between groups in terms of recanalisation (measured by venous ultrasonography examination), post-thrombotic symptoms or safety parameters. CONCLUSION: Enoxaparin can be used safely in DVT therapy during pregnancy. Our results indicate that therapy consisting of a single daily dose of 1.5 mg/kg enoxaparin is as effective as twice-daily administration.     

Postcoital haemoperitoneum: a cause for shock

Postcoital haemoperitoneum rarely occurs without evident vaginal injury. A 21-year-old second gravida woman presented to the ED in shock with a history of 8 weeks amenorrhoea and abdominal pain of 20 h duration. The ultrasound examination revealed a live intrauterine pregnancy and fluid in peritoneal cavity. There was a history of coitus 2 hours prior to the onset of pain. At laparotomy, more than 2 L of free blood was found in the peritoneal cavity. A small bleeding peritoneal vessel in pouch of Douglas was identified and ligated.     

创伤性脾破裂非手术治疗体会

目的探讨闭合性腹部外伤致脾破裂非手术治疗的可行性。方法对1996年10月~2006年10月收治的25例外伤性脾破裂患者的临床资料进行回顾性分析。结果非手术治疗25例,成功23例,成功率(92.0%)。结论选择合适的脾破裂患者行非手术治疗是安全、有效的。     

闭合性胸外伤合并脾包膜下破裂的诊治经验

1970年～1987年,我院收治的188例闭合性胸外伤中,有7例合并脾包膜下破裂,发生率为3.7％。脾包膜下破裂的主要症状体征是左上腹胀痛和深压痛,B超及CT检查有助诊断。作者认为对脾包膜下破裂宜采用保守治疗,对发生延迟破裂者,则尽量采用保留性手术。     

Effect of obesity on outcomes after fondaparinux, enoxaparin, or heparin treatment for acute venous thromboembolism in the Matisse trials

BACKGROUND: Selecting initial anticoagulant dose by patient weight for acute pulmonary embolism and deep vein thrombosis has clinical credibility; however, uncertainty remains regarding how to dose obese patients with newer anticoagulants because outcome data are sparse. OBJECTIVES: To use the Matisse trials' comparison of sc fondaparinux once daily with control heparin therapies (intravenous unfractionated heparin for pulmonary embolism, sc enoxaparin 1 mg/kg b.i.d. for deep vein thrombosis) for initial treatment in order to compare primary outcomes (venous thromboembolism recurrence and major bleeding) in obese patients. PATIENTS AND METHODS: Primary outcomes were compared in subsets composed of patients weighing < or = and > 100 kg and with body mass index (BMI) < 30 and > or = 30 kg/m(2). Medians and ranges for weight and BMI were compared for patients suffering either recurrence or major bleeding. RESULTS: Twenty-two thousand and one patients received fondaparinux and 2217 received enoxaparin or unfractionated heparin. Four hundred and ninety-six patients (11%) weighed > 100 kg and 1216 (28%) had a BMI > or = 30. Treatment groups had similar characteristics. The upper limit in subject weight for recurrence was 166 kg (BMI 58), and for major bleeding 120 kg (BMI 39). The incidences of recurrence and major bleeding were similar for each patient subset of weight and BMI for both fondaparinux and heparin treatment groups. Among patients with a primary outcome, median weights and BMIs were also similar. CONCLUSIONS: The current recommended doses of fondaparinux and heparins for the treatment of venous thromboembolism appear to provide similar protection against recurrence and major bleeding to one another and to obese and non-obese patients.     

腹腔镜下二级脾蒂离断法原位脾切除术治疗外伤性脾破裂的应用体会

目的探讨腹腔镜二级脾蒂离断法原位全脾或部分脾切除术对外伤性脾破裂（TSR）患者的疗效。 方法收集杭州市第一人民医院肝胆胰外科2012年6月至2015年8月间收治的17例TSR患者,结合术前CT检查和术中腹腔镜探查,并根据2000年第六届全国脾脏外科学术研讨会制订的脾损伤分级标准确定脾损伤等级,再行全脾切除或部分脾切除,并观察术中及术后恢复情况。 结果17例患者中Ⅰ级脾损伤3例,Ⅱ级5例,Ⅲ级7例,Ⅳ级2例。平均手术时间为（78 ± 12）min,平均回输自体血（750 ± 23）ml,平均出血量（220 ± 45）ml。所有病例均在术后3 d内肛门恢复排气并恢复饮食,平均住院（11.7 ± 2.1）d,且术后随访无相关远期并发症发生。 结论腹腔镜二级脾蒂离断法原位全脾或部分脾切除术治疗TSR患者安全有效。     

Undifferentiated shock in a cirrhotic patient: Ascites matters

In cirrhotic patients with undifferentiated shock, early CT with emphasis in ascitic fluid density should be performed to exclude rare causes of shock such as secondary peritonitis or hemoperitoneum.     

Rupture of a Splenic Artery Aneurysm in the First Trimester of Pregnancy

Background: Rupture of a splenic artery aneurysm during pregnancy is a rare and serious event, occurring mainly during the third trimester. The risk of rupture for an existing splenic artery aneurysm is very high during pregnancy (from 20% to 50%). When it does rupture, the maternal mortality rate is around 75% and the fetal mortality rate 95%. Of 110 cases reported in the literature, only one ruptured during the first trimester. Objectives: The aim of this case report is to make emergency physicians aware of this diagnosis, because only if it is considered can it be managed rapidly and appropriately. Case Report: We report the case of a 6-weeks pregnant patient referred to our institution in hemorrhagic shock who died of a ruptured splenic artery aneurysm shortly after surgery. The initial diagnosis considered was a ruptured ectopic pregnancy. Conclusion: We report this case to increase awareness of splenic artery rupture during pregnancy, even during the first trimester.