Scientific Foundation SPIROSKI, Skopje, Republic of Macedonia

Open Access Macedonian Journal of Medical Sciences. 2023 Jan 24; 11(C):92-95.
https://doi.org/10.3889/oamjms.2023.11375
eISSN: 1857-9655
Category: C - Case Reports
Section: Case report in surgery Since 2002

Internal Bleeding Management in Patient with Blunt Abdominal

Trauma at Rural Hospital: A Case Report of 40-Year-Old Male with
Spleen Rupture
Erlyn Tusara Putri Harjanti1 , Bobby Nindra2* , Andre Nindra3
1
Department of Emergency Room, RSK Ngesti Waluyo, Parakan, Indonesia; 2Department of General Surgery, RSK Ngesti
Waluyo, Parakan, Indonesia; 3Department of Anesthesiology, RSK Ngesti Waluyo, Parakan, Indonesia

Abstract
Edited by: Igor Spiroski BACKGROUND: Abdominal injury caused by blunt trauma is a common presentation in the emergency room.
Citation: Harjanti ETP, Nindra B, Nindra A. Internal
Bleeding Management in Patient with Blunt Abdominal
Especially in developing countries like Indonesia, the number of motor vehicle accident in public roads is still high.
Trauma at Rural Hospital: A Case Report of 40-Year-Old Eighty percentages of traumatic injury are blunt injury with the majority of deaths which are caused by hypovolemic
Male with Spleen Rupture. Open Access Maced J Med shock.
Sci. 2023 Jan 24; 11(C):92-95.
https://doi.org/10.3889/oamjms.2023.11375
Keywords: Internal bleeding; Unstable hemodynamic;
CASE DESCRIPTION: A 43-year-old man arrived at the emergency room after motorcycle accident 2 h before.
Spleen rupture AMPLE and primary survey was conducted: clear airway, spontaneous breathing, BP 70/palpation mmHg, HR
*Correspondence: Bobby Nindra, Department of
General Surgery, RSK Ngesti Waluyo, Indonesia.
123 times/min, and altered consciousness, in which showed the patient was undergoing hemorrhagic shock. The
E-mail: bobbynindrabedah@gmail.com patient was hemodynamically stable after being given 1 L of normal saline through two intravenous lines. FAST was
Received: 08-Dec-2022 conducted and intraperitoneal free fluid was seen in Morison’s pouch, left hemithorax, and pouch of Douglass. Chest
Revised: 26-Dec-2022
Accepted: 14-Jan-2023 X-ray showed fracture of ribs 7, 8, and 9 left lateral aspect with minimal hemothorax. After a supporting examination
Copyright: © 2023 Erlyn Tusara Putri Harjanti, was performed, the patient’s BP dropped to 60/40 mmHg, showing the patient was a “transient responder,” indicating
Bobby Nindra, Andre Nindra
Funding: This research did not receive any financial the patient should undergo laparotomy. The patient was given 500 mL colloid with a systolic target of 80–90 mmHg
support in accordance to permissive hypotension theory ± 1500 mL blood was found inside the abdomen during operation, a
Competing Interests: The authors have declared that no
competing interests exist
splenic rupture grade V was the cause. In the 5th day after surgery, the patient was discharged.
Open Access: This is an open-access article distributed
under the terms of the Creative Commons Attribution- CONCLUSION: Since blunt abdominal trauma could cause intraperitoneal bleeding that leads to hemorrhagic shock;
NonCommercial 4.0 International License (CC BY-NC 4.0) therefore, immediate diagnosis is needed. Multiple trauma management at rural hospital should be concordant to
ATLS and Schwartz’s Principles of Surgery.

Introduction BP 70/palpation mmHg, HR 123 times/min, and altered

consciousness with GCS E3V4M6. Two intravenous lines
were installed simultaneously with drawing bloods for CBC
Abdominal injury caused by blunt trauma and blood type. After being given 1L of normal saline,
is a common presentation in the emergency room the patient BP became 80/60 mmHg with HR 104 bpm.
with chief cause which is motor vehicle accident [1]. AMPLE was asked, he confessed that he did not have
Especially in developing countries like Indonesia, the any allergies, no medication that he take regularly, no past
number of motor vehicle accidents in public roads is medical history, and his last meal was 5 h before accident.
still high. Eighty percentages of traumatic injury are a He also confessed that he got crushed by his motorcycle,
blunt injury with the majority of deaths being caused by and at that time, he was in pain especially when breathing.
hypovolemic shock. Moreover, intraperitoneal bleeds Physical examination was conducted, the
occur in 12% of blunt trauma with liver and spleen patient looked pale. From lung auscultation, vesicular
being most commonly injured. Therefore, it is essential sound could be heard, but it was decreased around left
to identify trauma quickly [2]. SIC V–VI. From the patient’s abdominal examination,
can be seen on Figure 1, it was found that there was
lesion from his left chest until his left pelvic on inspection,
normal bowel sounds on auscultation, and from palpation
Case Description abdomen was a little rigid with rebound tenderness.
FAST and chest X-ray were conducted. FAST
results came out, intraperitoneal free fluid was seen in
A 43-year-old man arrived at the emergency Morison’s pouch, left hemithorax, and the pouch of Douglass
room after motorcycle accident 2 h before. Primary survey (Figure 2). Chest X-ray showed fracture of ribs 7, 8, and 9
was conducted: clear airway, spontaneous breathing, left lateral aspect with minimal hemothorax (Figure 3).

92 https://oamjms.eu/index.php/mjms/index
 Harjanti et al. Internal Bleeding Management in Patient with Blunt Abdominal Trauma:
Case
A Report

After a supporting examination was is the third most common cause of death regardless
performed, the patient’s BP dropped to 60/40 mmHg, of age. In 2014, there were almost 200,000 injury-
showed that patient was a “transient responder,” related deaths, but 37.2 million injured patients treated
indicating, the patient should undergo laparotomy. in emergency departments (EDs) [3]. ATLS provides a
The patient was given 500 mL colloid with systolic structured approach to the trauma patient with standard
target 80–90 mmHg in accordance to permissive algorithms of care that emphasizes the “golden hour”
hypotension theory. Colloid was used instead of blood concept so the doctor can prioritize which interventions
products since it was not available and the blood bank that needed to get done first to prevent death and
was distanced. disability.
Table 1: Signs and symptoms of hemorrhage by class The patient’s vital functions must be assessed
Parameter Class I Class II Class III Class IV (Severe) quickly and efficiently. Management consists of a rapid
(Mild) (Moderate) primary survey with simultaneous resuscitation of vital
Approximate Blood Loss <15% 15 – 30% 31 – 40% >40%
Heart Rate Normal Normal / ↑ ↑ ↑ / ↑↑ functions, a more detailed secondary survey, and the
Blood Pressure
Pulse Pressure
Normal
Normal
Normal
↓
Normal / ↓
↓
↓
↓
initiation of definitive care. The mechanism of injury,
Respiratory Rate Normal Normal Normal / ↑ ↑ injury forces, location of injury, and hemodynamic status
Urine Output Normal Normal ↓ ↓↓
GCS Normal Normal ↓ ↓ of the patient determine the priority and best method of
Need for Blood Product Monitor Possible Yes Massive Transfusion Protocol
abdominal assessment. The assessment of circulation
Around 1500 mL blood was found inside the during the primary survey includes early evaluation for
patient’s abdomen during operation, a splenic rupture possible intra-abdominal and/or pelvic hemorrhage
grade V was the cause. Due to the intraoperative in patients who have sustained blunt trauma. In
bleeding and the hemoglobin level was dropped into hypotensive patients, the goal is to rapidly identify an
9.5 g/dl, the patient was given one pack of PRC (Pack abdominal or pelvic injury and determine whether it is
Red Cell) after laparotomy operation. In the 5th day the cause of hypotension. Significant blood loss can
after surgery, the patient discharged with education to be present in the abdominal cavity without a dramatic
restrained his movement. change in the external appearance or dimensions of
the abdomen and without obvious signs of peritoneal
irritation [4].
Primary survey in this patient showed that the
Discussion patient was in hemorrhagic shock class III–IV according
to ATLS as seen on Table 1 with BP 70/palpation mmHg,
HR 123 bpm, and GCS E3V4M6.
Trauma is the most common cause of death for The patient was hemodynamically stable with
all individuals between the ages of 1 and 44 years and BP 80/60 mmHg and HR 104 bpm after being given
initial fluid therapy which was 1 l of normal saline.
The goal of resuscitation is to restore organ perfusion
and tissue oxygenation, which is accomplished with
administering crystalloid solution and blood products to
replace lost intravascular volume.
The need to identify trauma quickly is high
moreover when the patient is unstable. The optimal
test should be rapid, accurate, and non-invasive. The
FAST examination evaluates three potential spaces
a b within the peritoneal cavity which evaluates free
Figure 1: Lesion at the left lateral abdominal region from (a) AP and fluid in Morison’s pouch or the hepatorenal space,
(b) lateral positions left upper quadrant in subphrenic area and in the

a b c
Figure 2: FAST results, fluids seen in (a) Morison’s pouch, (b) left hemithorax, and (c) the pouch of Douglass

Open Access Maced J Med Sci. 2023 Jan 24; 11(C):92-95. 93

C - Case Reports Case report in surgery

rectovesical pouch in males, and the rectouterine estimated 15% to 40% of their blood volume (classes II
(Pouch of Douglas) and vesicouterine pouches and III hemorrhage) and the need for blood is moderate
in females [2]. In this patient, free fluid was found to high [4].
in all area which proved that the patient had intra- Since blood was not ready as of that moment,
abdominal bleeding. the patient was given 500 mL colloid with systolic target
80–90 mmHg in accordance to permissive hypotension
theory [5]. Permissive hypotension is the act of
maintaining a blood pressure lower than physiologic
levels in a patient that has suffered from hemorrhagic
blood loss to maintain adequate vasoconstriction, organ
perfusion, and prevent an undesired coagulopathy
during initial fluid resuscitation. Research favors
resuscitation to maintain systolic pressures of 80 mmHg
to 90 mmHg or a MAP of 40 mmHg to 60 mmHg [6], [7].
From Figure 4, with the patient’s unstable
hemodynamic state and positive FAST examination,
laparotomy should be done as soon as possible. The
only thing that needs to be determined in the emergency
department is if an exploratory laparotomy is necessary,
not which one intra-abdominal organ is harmed.
Figure 3: Chest X-ray results, fracture of ribs 7, 8, and 9, left lateral
aspect with minimal hemothorax Abdominal stiffness, which one of the symptoms of
abdominal compartment syndrome, and hemodynamic
Chest X-rays can show potentially life-
impairment in patient with traumatic injury are signs that
threatening injuries that require treatment or further
should elicit immediate surgical exploration [3], [8]. [9].
investigation. Chest X-ray from this patient showed that
there was fracture 7, 8, and 9 left lateral aspect with Around 1500 mL blood was found inside the
minimal hemothorax. Since the inability to breath was patient’s abdomen during operation, a splenic rupture
not prominent and the hemothorax shown from X-ray grade V was the cause. Due to the intraoperative, bleeding
was just minimal, thoracotomy was not conducted in and the hemoglobin level was dropped into 9.5 g/dl, the
this patient. One of the reasons is bleeding which is patient was given one pack of red blood cell [10], [11].
usually self-limited and does not require operative In the 5th day after surgery, the patient
intervention [4]. discharged with education to restrained his movement.
The patient’s response to initial fluid
resuscitation is the key to determining subsequent
therapy. After doing supporting examination, the
patient BP became deteriorate and the HR increased, Conclusion
indices as the initial fluids are slowed to maintenance
levels which shown either an ongoing blood loss or
inadequate resuscitation, this condition called transient Since blunt abdominal trauma could cause
response. Most of these patients initially have lost an intraperitoneal bleeding that leads to hemorrhagic

Figure 4: Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. Figure from Brunicardi F, Andersen DK, Billiar
TR, Dunn DL, Kao LS, Hunter JG, et al., editors. Schwartz’s Principles of Surgery. 11th ed. New York City: McGraw Hill; 2019

94 https://oamjms.eu/index.php/mjms/index
 Harjanti et al. Internal Bleeding Management in Patient with Blunt Abdominal Trauma:
Case
A Report

shock; therefore, immediate diagnosis and therapy are Lefering R, Bernhard M, et al. Synthetic colloid resuscitation
needed [1]. ATLS provides a structured approach to the in severely injured patients: Analysis of a nationwide trauma
registry (TraumaRegister DGU). Sci Rep. 2018;8(1):11567.
trauma patient with standard algorithms, so the doctor
https://doi.org/10.1038/s41598-018-30053-0
can prioritize which interventions that needed to get
PMid:30068966
done first to prevent death and disability. Multiple trauma
6. Das JM, Anosike K, Waseem M. Permissive Hypotension.
management at rural hospital should be concordant to Treasure Island (FL): StatPearls Publishing; 2022.
ATLS and Schwartz’s Principles of Surgery.
PMid:32644341
7. Kowalski A, Brandis D. Shock Resuscitation. Treasure Island
(FL): StatPearls Publishing; 2022.
PMid:30521251
References 8. Richman A, Burlew CC. Lessons from trauma care: Abdominal
compartment syndrome and damage control laparotomy in
the patient with gastrointestinal disease. J Gastrointest Surg.
1. O’Rourke MC, Landis R, Burns B. Blunt Abdominal Trauma. 2019;23(2):417-24. https://doi.org/10.1007/s11605-018-3988-2
Treasure Island (FL): StatPearls Publishing; 2022. PMid:30276590
PMid:28613739 9. Ahmed A, Azim A. Emergency laparotomies: Causes,
2. Bloom BA, Gibbons RC. Focused Assessment with Sonography pathophysiology, and outcomes. Indian J Crit Care
for Trauma. Treasure Island (FL): StatPearls Publishing; 2022. Med. 2020;24(Suppl 4):S183-9. https://doi.org/10.5005/
jp-journals-10071-23612
PMid:29261902
3. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, PMid:33354039
Hunter JG, et al., editors. Schwartz’s Principles of Surgery. 10. Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N,
11th ed. New York City: McGraw Hill; 2019. Available Fergusson DA, et al. Transfusion thresholds for guiding
from: https://accessmedicine.mhmedical.com/content. red blood cell transfusion. Cochrane Database Syst Rev.
aspx?bookid=2576&sectionid=216201149 [Last access on 2021;12(12):CD002042. https://doi.org/10.1002/14651858.
2022 Sep 04]. CD002042.pub5
4. American College of Surgeons. Advanced Trauma Life Support: PMid:34932836
Student Course Manual. 10th ed. Chicago IL: American College 11. National Clinical Guideline Centre (UK). Red blood cell:
of Surgeons; 2018. Thresholds and targets. In: Blood Transfusion. Ch. 10. London:
5. Hilbert-Carius P, Schwarzkopf D, Reinhart K, Hartog CS, National Institute for Health and Care Excellence (NICE); 2015.

Open Access Maced J Med Sci. 2023 Jan 24; 11(C):92-95. 95