Category Archives: General

Pop Quiz: The Answer

Tip of the hat to John Greenwood, who got the correct answer to this problem case. The CT shows that the patient developed a pseudoaneurysm in the spleen (A) with a fistula to the splenic flexure of the colon (B). This resulted in a sentinel bleed that caused an episode of hematochezia.

Could this have been detected at the initial presentation? No, since the pseudoaneurysm was not seen on the initial CT. There is little support in the literature for serial evaluation by CT, but this may be the one case (in a billion!) where it may have been useful. This should not be enough to change your ordering behavior, though.

How does the pseudoaneurysm result in a fistula to the colon? That’s a good question. Pseudoaneurysms typically grow until they rupture, resulting in troublesome bleeding. My suspicion was that there was also a colon injury at the splenic flexure due to the handlebar injury mechanism which allowed this process to develop. Otherwise it’s hard to envision a pseudoaneurysm burrowing through all layers of a normal colon for no real reason.

What’s the proper treatment? In my mind, only exploration with splenectomy and colon resection/repair is acceptable. Embolization of the spleen may reduce the likelihood of future bleeding, but there is still a potential abscess in the area and it’s very difficult to predict what it will do over time. 

Reference: Splenocolic fistula after nonoperative management of splenic rupture. Trauma 15(1):86-90, 2013.

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Pop Quiz: Hints

No correct guesses yet, but some good tries! Remember, this was a 16 year old male who crashed a motorcycle and sustained liver and spleen injuries. A month after successful nonoperative management, he presents with a single episode of hematochezia. 

Here’s a CT scan taken during the second ED visit:

What’s the problem? Any way to have detected it sooner? What to do now?

Comment or tweet your answers!

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Pop Quiz: Interesting Case!

A 16 year old male was thrown against the handlebars during a motorcycle crash at about 40 mph. He dusted himself off and went home for a few hours. Unfortunately, he slowly developed some abdominal pain.

He presented to an ED several hours later. He was found to have mild, diffuse abdominal pain, normal vital signs, and a positive abdominal FAST exam. CT scan showed a grade IV spleen injury and a grade II liver injury in the right lobe with no extravasation or pseudoaneurysm noted. He was successfully treated nonoperatively and was sent home.

One month later he returns to the ED complaining of a single episode of hematochezia (approximately 200cc). He has an entirely normal exam and vital signs.

Here are my questions for you:

  • Was the initial management appropriate?
  • Should anything additional have been done during the first admission?
  • What is the diagnosis now?
  • What diagnostic or therapeutic maneuvers are indicated now?

Please tweet your guesses, or leave comments below. Hints tomorrow and answers on Friday. Good luck!

Patient not treated at Regions Hospital

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What’s The INR Of Fresh Frozen Plasma?

So what’s the INR of FFP? Or stated another way, what’s the lowest you can correct a patient’s INR using infusions of fresh frozen plasma?

One of the mainstays of correcting coagulopathy, either from hemorrhage or due to medication like warfarin, is transfusion of FFP. Frequently, clinicians will write orders to administer FFP until a certain INR is achieved. What is a reaonable INR?

A “normal” INR is 1.0, plus or minus about 0.2, depending on your laboratory. However, two separate studies have shown that transfusion of FFP will not reliably decrease the INR below about 1.7. 

Bottom line: The answer to the question is about 1.6. If any clinician orders FFP transfusions with a goal INR below this, it probably won’t happen. And since transfusions of any product have risks, my “juice to squeeze” ratio of risk vs benefit begins to fail at an INR of 1.6. Below that point, the patient needs a normal temperature and good perfusion to drop their INR further.

References:

  • Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. Am J Clin Pathol 126(1):133-139, 2006.
  • Effect of fresh frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion 46(8):1279-1285, 2006.
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Best Of: CT Contrast Via Intraosseous Catheter

The standard of care in vascular access in trauma patients is the intravenous route. Unfortunately, not all patients have veins that can be quickly accessed by prehospital providers. Introduction of the intraosseous device (IO) has made vascular access in the field much more achievable. And it appears that most fluids and medications can be administered via this route. But what about iodinated contrast agents via IO for CT scanning?

Physicians at Henry Ford Hospital in Detroit published a case report on the use of this route for contrast administration. They treated a pedestrian struck by a car with a lack of IV access sites by IO insertion in the proximal humerus, which took about 30 seconds. They then intubated using rapid sequence induction, with drugs injected through the IO device. They performed full CT scanning using contrast injected through the site using a power injector. Images were excellent, and ultimately the patient received an internal jugular catheter using ultrasound. The IO line was then discontinued.

This paper suggests that the IO line can be used as access for injection of CT contrast if no IV sites are available. Although it is a single human case, a fair amount of studies have been done on animals (goats?). The animal studies show that power injection works adequately with excellent flow rates. 

The authors prefer using an IO placement site in the proximal humerus. This does seem to cause a bit more pain, and takes a little practice. A small xylocaine flush can be administered to reduce injection discomfort in awake patients. Additionally, the arm cannot be raised over the head for the torso portion of the scan. 

Bottom line: CT contrast can be injected into an intraosseous line (IO) with excellent imaging results. Insert the IO in a site that you are comfortable with. I do not recommend power injection at this time. Although the marrow cavity can support it, the connecting tubing may not. Have your radiologist hand-inject and time the scan accordingly.

Note: long term effects of iodinated contrast in the bone marrow are not known. For this reason, and because of smaller marrow cavities, this technique is not suitable for pediatric patients.

Related posts: 

Reference: Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals Emerg Med 57(4):382-386, 2011.

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