A 24-year-old motorcyclist is involved in a head-on collision with a motor vehicle and suffers various traumatic injuries. She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago. On arrival, her temperature is 36.7°C (98°F), blood pressure is 82/63 mmHg, pulse is 120/min, respirations are 20/min, and oxygen saturation is 97% on 2L oxygen nasal cannula. On physical exam, there are extensive ecchymoses and abrasions along her left posterior ribs and left flank. A CT scan of the abdomen is obtained, which is shown in Figure A. After the appropriate surgical intervention is performed for the grade V splenic injury, which of the following is the most appropriate next step in management?
Insertion of a nasogastric tube
Tetanus vaccination
Insertion of a thoracostomy tube
Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae
Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae
This patient has an extensive splenic injury and hemodynamic instability requiring splenectomy, as evidenced by trauma to the left posterior ribs and left flank, low blood pressures with reflex tachycardia, and evidence of splenic rupture and hemoperitoneum on computed tomography imaging. Subsequently, this asplenic patient will require vaccination against encapsulated bacteria such as S. pneumoniae, N. meningitidis, and H. influenzae.

The capsules of encapsulated bacteria serve as an antiphagocytic virulence factor. To clear these bacteria, opsonization and subsequent clearance by the spleen must occur. In the setting of asplenia, opsonization capability is significantly decreased and thus asplenic patients are at high risk of severe infections by encapsulated bacteria. As such, asplenic patients require vaccination against the encapsulated bacteria S. pneumoniae, N. meningitidis, and H. influenza.

Patton et al. review recommendations for serogroup B meningococcal vaccination. The authors find that for patients aged 10 to 25 years old who are at increased risk for meningococcal disease (asplenic patients); 3 doses of the MenB-FHbp vaccine should be given. The authors recommend the administration of only 2 doses of the vaccine to patients that are not at elevated risk.

Figure/Illustration A depicts a traumatic splenic rupture with perisplenic hemoperitoneum (red circle).

Incorrect Answers:
Answer A: Insertion of a nasogastric tube would be appropriate in a patient with bowel obstruction or significant post-operative ileus. There is no evidence that this patient is experiencing obstruction or ileus, which typically presents with nausea, vomiting, abdominal pain, bloating, and lack of flatus or bowel movements.

Answer B: Insertion of a thoracostomy tube is not indicated in this patient as there is no evidence of pneumothorax or hemothorax. Patients with pneumothorax or hemothorax typically present with tachycardia, tachypnea, and decreased oxygen saturation. On exam, such patients may have decreased breath sounds. Ultrasonography may also reveal the absence of lung sliding.

Answer C: Prophylactic intravenous antibiotics are not indicated in the immediate post-operative period for asplenic adults. However, daily oral antibiotic prophylaxis is indicated in asplenic patients with a history of another concurrent immunocompromising condition or a history of severe infection due to an encapsulated organism.

Answer D: Tetanus vaccination is indicated every 10 years in patients who have previously received 3 doses of the tetanus vaccine and have clean or minor wounds. In patients with more extensive wounds who have previously received 3 doses of tetanus vaccine, re-vaccination is only necessary if their last tetanus vaccine was 5 or more years ago. This patient has extensive abrasions but is up to date on all vaccines and last received a tetanus vaccine 3 years ago, so a re-vaccination during this time is not indicated.

Bullet Summary:
Asplenic patients are at increased risk of severe infection by encapsulated bacteria; thus patients that undergo splenic removal require vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae within 14 days of the procedure.