Okay, time for the answer. This 12 year old crashed his moped, taking handlebar to the mid-epigastrium. Over the next 3 days, he felt progressively worse and finally couldn’t keep food down.
Mom brought him to the ED. The child appeared ill, and had a WBC count of 18,000. The abdomen was firm, with involuntary guarding throughout and a hint of peritonitis. The diagnosis was made on the single abdominal xray shown yesterday. A closeup of the good stuff is above.
Emergency docs, your differential diagnosis list with this history is a pancreatic vs a duodenal injury based on the mechanism.
Classic findings for duodenal injury:
- Scoliosis with the concavity to the right. This is caused by psoas muscle irritation and spasm from retroperitoneal soiling by the duodenal leak.
- Loss of the psoas shadow on the right. Hard to see on this xray, but the left psoas shadow is visible, the right is not. This is due to fluid and inflammation along this plane.
- Air in the retroperitoneum. In this closeup, you can actually see tiny bubbles of leaked air outlining the right kidney. There are also bubbles along the duodenum and a few along the right psoas.
We fluid resuscitated first (important! dehydration is common and can lead to hemodynamic issues upon induction of anesthesia) and performed a laparotomy. There was a blowout in the classic position, at the junction of 1st and 2nd portions of the duodenum. The hole was repaired in layers and a pyloric exclusion was performed, with 2 closed drains placed in the area of the leak.
The child did well, and went home after 5 days with the drains out. Feel free to comment or leave questions!
I’ll be travelling through France for the next two weeks, stopping by a few hospitals to visit, I hope. France is in my top 10 list of international readers. And interestingly, most of my French readers are not in Paris!
Most of my posts will be “Best Of” while I am away. Additionally, there will not be a Trauma MedEd newsletter this month. But I’ll make it up to you in June!
Follow my progress on FourSquare and Twitter! I hope to meet some of my international readers out there! Tweet me if I’m in your neighborhood.
Here’s a case related to yesterday’s post on preventing handlebar injuries. Have a look at this image:
This alone is enough for you to make the diagnosis. More info, and answers tomorrow.
“Necessity is the mother of invention”
I’ve managed several cases of injury due to bicycle handlebars over the years. Typically, a smaller child crashes his or her bike, and the handlebar hits them in the epigastrium. Children have thinner abdominal walls and less developed muscular to protect them, so this very focal impact can do a lot of damage.
There is now a clever and inexpensive solution available that can decrease the number of injuries we see from this common mechanism. It’s called the Handlebar Helmet, and was developed by the parents of a 4 year old boy who suffered this injury. It is essentially a special plastic cap that fits on the end of the handlebars. It’s designed to diffuse the pressure of any impact with the handlebar. This product actually does double duty, protecting during a crash, and also preventing injury if a child trips and falls on a bike that is lying down.
The product is very easy to install, and comes in multiple colors so it can be “cool” (very important to kids). This is a nice, simple idea that can prevent potentially devastating injuries.
Over the next two days, I’m going to rerun an interesting pediatric case of handlebar injury.
Reference: The Handlebar Helmet. www.handlebarhelmet.com
Note: I have no financial interest in this product.
For a long time, we “knew” that pulmonary emboli were a possible and dreaded complication of deep venous thrombosis (DVT). However, we are beginning to discover that this is not always the case. The group in San Diego decided to see if there really are two different types of PE in trauma, and what that means.
Scripps Mercy Hospital, a level I trauma center, looked at 5 ½ years of their experience with adult trauma patients who were routinely screened for DVT. Any of these patients who developed a PE within 6 weeks of admission were evaluated further.
Here are the factoids:
- Duplex screening from groin to ankle was carried out twice weekly in ICU patients, and once weekly in ward patients
- Surveillance was carried out if the patient would be non-ambulatory for more than 72 hours, or were at moderate or higher risk for DVT using the ACCP guidelines
- Nearly 12,000 patients were evaluated by the trauma service and 2,881 underwent surveillance
- 31 patients (1%) developed a PE
- 12 of these 31 had DVT identified before or immediately after their PE. Clot was below-knee in 9 (!), above-knee in 2, and in the IJ in one.
- 19 patients had PE but no DVT identified (de novo PE, DNPE)
- DNPE tended to be single and peripherally located, and associated with rib fractures, pulmonary contusions, blood transfusions, and pneumonia
- DVT + PE were more often found in multiple lobes or bilaterally
Bottom line: Like most, this is not a perfect study, but it’s a really good one. It is looking more and more likely that some PEs arise de novo, without any associated DVT. These clots are more likely to be linked to some type of inflammatory process, and have a tendency toward causing more of the classic signs and symptoms of PE. There are still lots of questions to be answered, like do you need to anticoagulate the de novo PEs? But for now, no change in practice. Just be aware that these might not be as bad as they seem.
Reference: Pulmonary embolism without deep venous thrombosis: de novo or missed deep venous thrombosis? J Trauma 76(5):1270-1281, 2014.