All posts by TheTraumaPro

What The Heck? Final Answer!

This case involved a young male who had undergone a splenectomy for blunt trauma. He had an unremarkable postop course and was discharged after 5 days. He presented 2 weeks later with abdominal pain out of proportion to his exam. 

The first CT scan hint showed pneumatosis of the cecum, which is decidedly unusual in a young person:

The next CT scan hint showed thrombosis in the superior mesenteric vein:

This case illustrates an uncommon yet dangerous complication of splenectomy: portal and mesenteric veinous thrombosis. It is generally believed to be caused by thrombocytosis resulting from the splenectomy. The pneumatosis is most likely due to problems resulting from venous congestion.

In this particular case, the patient’s abdominal exam was not consistent with a catastrophic problem (yet). He was taken quickly to the interventional radiography department, where a catheter was inserted and lytic therapy was begun. HIs pain resolved, and repeat CT showed recanalization of much of his portal and mesenteric venous system, as well as resolution of the pneumatosis. He was discharged on warfarin therapy.

Bottom line: Uncommon and dangerous: a bad combination. This often results in delayed diagnosis and severe abdominal complications, including loss of much of the intestine. Monitor the platelet count closely postop until it plateaus, and if it still rising on discharge from the hospital, arrange for monitoring as an outpatient. Dogma tells us to treat with aspirin or similar drugs as the count approaches 1 million/cubic mm, but good studies are lacking. Development of this particular complication requires anticoagulation, and possibly lytics or surgical resection depending on patient condition.


Hat tip to StillChucklesandNP for getting the answer with limited information, and whom I had the pleasure of meeting on a recent visit to her hospital!

What The Heck? Some Hints!

Yesterday, I presented the case of a young man with abdominal pain a few weeks after a splenectomy for trauma. One slice of the CT scan was presented, which showed pneumatosis in the wall of the cecum.

There have been some great comments from readers with some interesting reasoning, especially from StillChucklesandNP. Here’s another piece of the puzzle, yet another slice from the CT scan:

  • What’s this?
  • Any other important information?
  • What’s the diagnosis and why?
  • How do you treat it?

Looking forward to more tweets and comments! Answers tomorrow.

What The Heck?

Here’s an interesting one for you to solve!

A 20ish year old male was involved in a motor vehicle crash, sustaining a Grade IV spleen injury. He fails nonoperative management early in his hospital course, undergoing a splenectomy 6 hours later.

He has an uneventful recovery and is ready for discharge after 5 days. His platelet count has plateaued at 600K. He presents to your ED 2 weeks later complaining of abdominal pain. On exam, he is diffusely but mildly tender. His subjective complaints appear to be a bit out of proportion to his exam.

Here is one slice from his CT scan. I’ve put a nice fat arrow on it to help out. But it won’t.

image

  • What does the scan show?
  • Why is it there?
  • What other key piece of information do you want to know?
  • Any other studies?
  • Then what?

Some hints tomorrow! Tweet your answers or leave comments below! Let’s see if anyone can figure this one out!

The Medical Orthopaedic Trauma Service

Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.

A few hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture. 

This medical center  published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.

Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.

Related posts:

Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma, ePub ahead of print, doi: 10.1097/BOT.0b013e3182242678, Aug 27, 2011.

How Not To Write An Abstract

I always encourage people to be careful when reading abstracts. Read the entire article, I say. Here’s a perfect example of why this is true.

Artificial blood products have been one of the holy grails of trauma for decades. Typically, a new one is developed, shows promise, then flames out for one reason or another. MP40X is yet another hemoglobin molecule that has been shown to improve tissue oxygen delivery. A multi-center clinical study was designed to look at clinical outcomes in real trauma patients. The study involved 38 hospitals, and was placebo controlled. Only patients in hemorrhagic shock with an elevated serum lactate were enrolled. The primary outcome was survival at 28 days.

Here are the factoids:

  • 313 patients were successfully studied over 17 months, with nearly equal numbers of MP40X vs normal saline controls
  • The two groups were well-matched for the usual demographics
  • Mortality for MP40X was 12% vs 14% for controls (not significant)
  • Serious adverse events were the same (36% vs 37%)
  • 57% of MP40X patients were alive at 28 days vs 50% of controls (not significant)
  • Ventilator-free days, hospital-free days, and organ failure was the same between the groups

However, the authors conclude:

While there were promising trends to suggest a potential for improved outcomes, the study was underpowered to confirm the efficacy of MP40X in trauma hemorrhage.”

Bottom line: When someone designs a study, especially a multi-center study that lots of people will spend their time and money on, the investigators are responsible for doing it right. This includes trying to estimate how many patients are needed to have a chance of showing a significant difference. Granted, this may be somewhat difficult with a new product or drug, but at least estimate on the high side.

This study abstract blames the lack of results on not having enough subjects. If that is truly the case, the reasons for underpowering it should be explained in the abstract. Otherwise, it just looks like they are making excuses and raise hopes for an ineffective product.

Reference:Effects of MP40X, an oxygen therapeutic, on clinical outcomes in trauma patients with hemorrhagic shock: a Phase IIb multi-center randomized placebo-controlled trial. AAST 2013, Paper 15.

A hat tip to the Skeptical Scalpel for bringing this paper to my attention.