Tag Archives: pop quiz

Pop Quiz: What’s The Diagnosis? The Answer

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!

Now Where Did That Bullet Go? The Answer!

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.

Now Where Did That Bullet Go?

Here’s an interesting case for you to consider. A male victim of an assault is brought to your emergency department with a gunshot to the abdomen. He is met by your team as a trauma activation. Vitals are stable, but he has guarding and rigidity. A single abdominal x-ray is obtained, and then the patient is taken off to surgery. I’ve marked the entry site on the anterior abdominal wall below. There is no exit wound.

In the operating room a laparotomy is performed. There is a hole in the fascia under the skin penetration. A small hematoma is seen in the underlying transverse mesocolon, well away from the bowel itself. An extensive search is carried out, but no other holes, injuries, or evidence of a bullet is found. Ultimately, the abdomen is closed and the patient is admitted to a ward bed.

WTF? Where did the bullet go? What do you think the possibilities are? Please leave comments today either here or on Twitter. I’ll analyze this puzzling situation tomorrow!

Disclosure for my social media compliance police: this patient was not treated at Regions Hospital, and the x-ray was obtained and modified from the internet.

What Would You Do? Incidental Pulmonary Embolus

You recently received a trauma activation patient after a high speed car crash. She was restrained with belts and airbags, and really has minimal trauma. There is clinical evidence of a few right-sided rib fractures, and nothing else. She has no significant past medical history, but is overweight to obese. You estimate the BMI as about 31.

Following your blunt trauma imaging protocol, one of the scans you obtain is a chest CT. It confirms that the aorta has not been injured and shows two rib fractures. After review, the radiologist calls you with a puzzling result. The patient has a small pulmonary embolus seen in a distal (third order) branch of the pulmonary artery in the left lung.

Here’s a coronal view of the scan that you looked at. The arrows show some peripheral branches, but you didn’t see anything on your average resolution monitor.

image

Here’s a sagittal view in high-rez that the radiologist looked at.

image

Yup, looks like a pulmonary embolus. Here are my questions:

  • Where did it come from?
  • What do you do next?
  • What type of treatment is needed?

Think this over this weekend. Discussion and answers on Monday.