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.

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.

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

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.

Yesterday, I showed you an x-ray of a trauma patient and asked you to tell me all the pertinent things that you saw. Here’s the x-ray again:

And here’s the list of all the things that struck me about it. Tomorrow, I’ll explain how I figured them all out from just this x-ray.

• The patient is a female
• She is still on a backboard
• She was stabbed with a long, professional cooking knife
• The assailant was right handed
• The course of the knife is left to right, superior to inferior, and anterior to posterior
• She was unstable, either blood pressure or respirations
• The patient was intubated, most likely due to hypotension and unresponsiveness (BTW, the tube is deep and needs to be pulled back)
• There is a moderate left hemothorax
• The mediastinum is shifted to the right
• A deep sulcus sign is present, either from a pneumothorax that is not easily visible, or from a large hemothorax (more likely the first one)
• Intra-abdominal and diaphragmatic injury is almost certain
• A pulmonary contusion is present on the left
• The stab enters the antero-lateral chest
• It does not involve the arm or axilla
• The patient needs a chest tube now
• She must be taken to the OR immediately after the tube

Some of these are easy, some are not. Let me know if you found anything else by tweeting or commenting below.

Sometimes we are way too focused. Commonly, trauma professionals will look at a lab result / image / patient / etc and only see what they are looking for.

Here’s an exercise to help you break out of that trap. I want you to look at this image and make a list of all the non-trivial things you see and think about that are pertinent to the case. Like “there is a knife in, on, or under the patient” and not like “the patient has ribs.”

Tomorrow, I’ll go over my list of 16 items. See if you can find them all, or more! On Thursday, I’ll explain how I figured out each item. Good luck!

Hit me with your key findings via Twitter, or comment below!

You are working in your local emergency department and are notified of an incoming trauma patient. The victim was involved in a car crash at highway speeds, was not restrained, and was partially ejected from the driver’s side window.

Pre-arrival report from the medics indicate that he has a BP of 146/90, pulse of 130, and a respiratory rate of 36. He is very dyspneic and complains that he can’t breathe. They state that the only abnormality that they found on their exam was some bony crepitus over the left lateral chest.

When he arrives, he is exactly as billed. O2 saturations are 82%, and he is in obvious respiratory distress. Breath sounds are quite diminished on the left.

What are the potential diagnoses?

What do you do next? Here are your choices:

• Examine the airway
• Apply supplemental oxygen
• Intubate
• Obtain a chest x-ray
• Decompress the left chest with a needle
• Insert a chest tube
• Proceed to the operating room
• Obtain a CT scan of the torso

Please tweet or leave comments with your suggestions. I’ll review your choices on Monday, and provide some followup information. Final answer on Tuesday!