Tag Archives: pop quiz

Abdomen, Pop quiz

What Would You Do? Teensy Weensy Stab To The Abdomen – Part 2

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Yesterday, I presented the case of a young man with a teensy weensy little stab to his abdomen, just above the umbilicus. There was a tiny bit of oddly colored fat that was visible in the wound. So now what should we do?

The first thing is to figure out what that bit of fat is. It doesn’t have the normal large pebbling and color of subcutaneous fat. Therefore, it must be a small piece of omentum protruding from the wound.

And what is the significance of that? This question has been addressed by papers with low numbers of subjects since the 1980s. It really depends on what country you are located in. Do you have readily available OR resources? Are there pressures to minimize hospital stays (US)?

One of the earliest papers originated from Parkland Hospital in Dallas TX. They reviewed 115 cases of omental evisceration over a 4 year period, and found that “serious” abdominal injuries were found in 75% of them. All went to laparotomy, and injuries to not one, but two organs were noted in about half of the positive cases. There was a 7% complication rate with negative laparotomy,

Contrast this with a study from Kingston, Jamaica where 66 patients with abdominal stabs and omental evisceration were treated. Of these, 14 were treated with observation because they had a normal abdominal exam. All were treated successfully without operation. But note the ratio here: 14/66 = 21%, which is the same as the negative laparotomy in the Parkland study (25%). So this study implies that if the patient can be watched and does not develop symptoms, the negative lap may be avoided.

Unfortunately, in many countries there are pressures to get people out of the hospital as soon as possible. Since small bowel content is relatively benign (at first), patients may not become symptomatic for several days. It would probably be difficult to convince your hospital to keep patients laying around for serial exams for days on end. Not to mention the logistical problems of doing good serial exams.

So most trauma professionals will be compelled to do something. And what should we do? Here are some possibilities. Pick your poison, and I’ll give you my choice tomorrow.

  • Local wound exploration
  • CT scan of the abdomen
  • Proceed to the operating room

As before, leave a comment to let me know what you would do. Or tweet it out!

References:

  1. Significance of omental evisceration in abdominal stab wounds. Am J Surg 152(6):670-673, 1986.
  2. Non-operative management of stab wounds to the abdomen with omental evisceration. J Royal Col Surg Edin 41(4):239-240, 1996.
Pop quiz

What Wound You Do? A Teensy Weensy Stab To The Abdomen

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Here’s a case to test your mettle! A young male walks into the triage desk in your ED with a teensy weensy little puncture just above his umbilicus. Your triage nurse, who is very astute, recognizes that this meets your trauma activation criteria and pushes the button. The gentleman is escorted to your trauma bay and the team quickly assembles to evaluate him.

Vital signs are stable, and no other wounds are found. There is a very small 1cm stab located about 2cm above the umbilicus, perfectly in the midline. The abdomen is soft and nontender, and the patient wants to know why everyone is making such a big deal about this.

Upon close inspection of the wound, there is a very small piece of bright yellow fat protruding 2mm from the wound. It somehow doesn’t look like the subcutaneous fat around it.

Here are the questions that I’ll be addressing over the next several posts:

  • What do you think of the appearance of the patient and his wound?
  • Where should we go next?
  • What are our diagnosis and management options?

In my next post, we’ll discuss how we diagnose this patient and whether there is a real problem here.

What do you think is going on? What is it? What do we do next? Leave a comment here, or tweet out your answers before tomorrow!

Pop quiz

Pop Quiz: What’s The Diagnosis? The Answer

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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. Here is a close-up of the good stuff?

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 common or leave questions!

General

Now Where Did That Bullet Go? The Answer!

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Previously, I presented a scenario where a victim of a gunshot to the abdomen was taken to the OR after obtaining the image below. No bullet was seen on the x-ray, and none was found at the time operation.

image

Where could it have gone? Let’s assume that the surgeon did a good job, and it is not in the abdomen. Any more. There are several possibilities.

Does the x-ray cover the correct area? To cover a straighforward abdominal gunshot, it needs to show diaphragms to perineum, side to side. In these days of “super size me”, that usually doesn’t happen with one image. Look carefully at the one above. It doesn’t show any portion of the diaphragm, and doesn’t go low enough, either. And although the right flank can be seen, the left is cut off. So in this case, the bullet could be in the soft tissues of the torso, in the extraperitoneal rectal area, or near the diaphragm in the liver.

It could have moved outside the area of the initial x-ray. The most common mechanism for this is entry into the vascular system. If it enters the venous system, it will end up in the heart or pulmonary artery somewhere. This will be obvious when you get a chest x-ray. If it enters the aorta, it will embolize into the lower extremities. This fact should be painfully obvious when you check the pulses in the lower extremities. 

The patient could poop it out if it entered their GI tract. This could happen if you wait to get additional images of the abdomen. If you bracket it with x-rays immediately, this should not happen. 

In theory, the bullet could enter the bladder and get urinated out. This won’t happen if a catheter is in place. And it’s probably unrealistic because most bullets would cause tremendous pain passing, and would probably obstruct the urethra anyway.

Finally, it could have bounced. Never count on this one. Bullets can and do enter partially, then stop or fall out. They can cause underlying perforation of the peritoneum, and they can bruise nearby structures. This is extremely uncommon and should be a diagnosis of last resort!

Bottom line: If patient condition permits, the patient with a gunshot to the abdomen who will be taken to the OR should have any wounds marked and an initial abdominal image obtained that shows the entire abdomen. This may take multiple attempts. The image can be very helpful in directing the exploration and finding wounds. If it is not seen on the initial image(s), check the lower extremity pulses and obtain a chest x-ray to locate the bullet prior to the case.