Tag Archives: pop quiz

Pop Quiz: Delayed Answer!

Well, it took me a month to figure out that one of my pop quiz answers was posted to the wrong area! The link provided with the tweet would have gotten you to it, but those who were following along on tumblr may have been mystified. Here’s the answer again.

Here’s a link to the original post/quiz.

So the question was to guess the exact mechanism of injury given the x-ray below.

The image shows a stomach bubble located in the left chest, indicating a left sided diaphragm rupture. In countries with left sided drivers, this is a classic injury from a t-bone type impact directly on the driver side door. The arm rest is driven into the driver’s flank, or on occasion the driver is partially ejected through the window. The impact raises abdominal pressure abruptly and can push the abdominal contents (typically stomach, followed by spleen) through the weakest area of the diaphragm.

Practical tip: These patients may present with tachypnea and decreased breath sounds on the left side. The usual reflex is to insert a chest tube, which is unneeded and won’t help in this case. What the patient really needs is an NG tube to help their breathing (and an immediate trip to the OR). So if you encounter this clinical combination plus a significant left sided impact (car crash, pedestrian struck), get a chest x-ray first if the patient’s condition will tolerate it. 

And again, hats off to precordialthump for getting it exactly right!

Pop Quiz Hints

All right, you’re good! Many people concluded that this was blunt trauma, and that there was something wrong with the diaphragm. Several people went so far as to say it was a motor vehicle crash.

Great so far! But take it one step further and tell me exactly what happened in this crash. You know, speed, direction, mass, all that physics stuff! Final answer tomorrow!

Pop Quiz! DPL – The Answer!

You’re doing one of those (very rare) DPLs and get a surprise result. Not blood, not obvious intestinal content, but just a small amount of mysterious sediment. What to do?

Well, this is obviously not normal. Therefore, this has to be considered a positive diagnostic peritoneal lavage. Since DPL is a qualitative test (meaning that the answer is only yes or no), the patient must go to the OR.

Here are the answers to the questions posed earlier today:

  • The DPL catheter has a relatively small diameter, so leave it in place! It may be very difficult to find where it went otherwise
  • Midline laparotomy incision is most appropriate. Remember, this is a trauma case? However, you can start infra-umbilical with a limited incision.

Here’s what I found in this case:

The catheter went straight into the cecum! So we actually did a diagnostic colonic lavage! The sediment was a very small amount of stool. And as stated above, had the catheter not been left in place, it would have been very tough to find the puncture site. 

Next, I clamped the catheter to keep it in place, cut it on the hub side, and removed most of it.

Finally, I placed a purse-string stitch around the entry site in the bowel, removed the catheter and tied the suture.

But wait, we’re not done yet! The patient did have abdominal pain and a seat belt sign, so we did a trauma exploration through the midline incision. A Grade II liver injury was present which needed no further management. The patient did well  and was discharged on the fourth day.

Bottom line: Procedures can and do go awry. Reason your way through it the best you can, then use focused diagnostics, if needed, to come up with a plan. For misplaced needles and catheters, most organs can tolerate a puncture by almost anything (except the eye, maybe). Treat appropriately and monitor carefully afterwards.

Source: Personal archive. Not treated at Regions Hospital