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Splenic rupture: an additional complication of thrombolytic therapy

Because nurses often have more interaction with hospitalized patients than physicians and are frequently the first to notice and report problems with patients, I wish to comment on the article, "Reteplase: Nursing Implications for Catheter-Directed Thrombolytic Therapy for Peripheral Vascular Occlusions" (June 2002:57–63). The author lists several of the possible complications of thrombolytic therapy in Table 3 of the article. Although these complications may be the most frequently encountered, nurses should be aware of another complication that can be fatal if not recognized and treated early—splenic rupture. This complication of thrombolysis has been associated, albeit rarely, with the use of streptokinase, tissue plasminogen activator, and urokinase.^1–9 Some of these agents are no longer approved by the Food and Drug Administration for thrombolysis (ie, urokinase), but the potential risk for splenic rupture may still exist in patients receiving thrombolytic therapy with newer agents, such as alteplase or reteplase.

Although splenic rupture in thrombolyzed patients is an infrequent complication, the necessity for early recognition and medical and/or surgical management is obvious considering the potential lethality of this condition. Patients with splenic rupture may report a constellation of symptoms, such as nausea, anorexia, weakness, dizziness, abdominal pain or discomfort, and left shoulder pain (Kehr’s sign). Examination may reveal tenderness or a palpable mass in the left upper quadrant, along with a pale appearance, tachypnea, tachycardia, hypotension, absent or hypoactive bowel sounds, abdominal distension, or signs of peritoneal irritation. An immediate or stat hematocrit value may be reduced from previous values. The range and variability of signs, symptoms, and physical findings seen in cases of rupture have been simplified for brevity, but those above should suggest the possibility of splenic rupture. And it is worth noting that, in the absence of known antecedent trauma, splenic rupture can be confused with other conditions, such as myocardial infarction or ruptured peptic ulcer.

Nurses are instrumental in the early detection of signs and symptoms that may suggest splenic rupture in patients receiving thrombolytic therapy. This condition should especially be suspected in patients with prior splenic injury due to trauma or diseases affecting the spleen. Early recognition of this rare complication of thrombolysis, along with prompt medical and surgical intervention, affords such patients the best possibility of survival.

References

1. Eklof B, Gjores J-E, Lohi A, Staszkiewicz W, Norgren L. Spontaneous rupture of liver and spleen with severe intra-abdominal bleeding during streptokinase treatment of deep venous thrombosis. Vasa. 1977;6:369–371.[Medline]
2. Norgren L, Eklof B, Gjores JE, Lohi A, Staszkiewicz W. Spontaneous rupture of liver and spleen during streptokinase treatment of deep venous thrombosis [in Swedish]. Lakartidningen. 1978;75:777–778.[Medline]
3. Wiener RS, Ong LS. Streptokinase and splenic rupture. Am J Med. 1989;86:249.
4. Gardner-Medwin J, Sayer J, Mahida YR, Spiller RC. Spontaneous rupture of spleen following streptokinase therapy. Lancet. 1989;2:1398.
5. Blankenship J, Indeck M. Splenic hemorrhage after tissue plasminogen activator for acute myocardial infarction. N Engl J Med. 1991;325:969.[Medline]
6. Lambert GW, Cook PS, Gardiner GA, Regan JR. Spontaneous splenic rupture associated with thrombolytic therapy and/or concomitant heparin anticoagulation. Cardiovasc Intervent Radiol. 1992;15:177–179.[Medline]
7. Blankenship JC, Indeck M. Spontaneous splenic rupture complicating anticoagulant or thrombolytic therapy. Am J Med. 1993;94:433–437.[Medline]
8. Jayamaha AS, Patel JK, Orlikowski C. Splenic rupture following streptokinase therapy. Intensive Care Med. 1994;20:244.[Medline]
9. Nam R, Carr MM, Jamieson CG. Delayed rupture of the spleen and streptokinase therapy. Can J Surg. 1996;39:151–154.[Medline]

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