Tag Archives: pop quiz

Pop Quiz! The Case

A young man presents to your emergency department walk-in area. Something is wrong with his head. Here is an AP skull film (when is the last time you got one of those?)

I’ll walk you through my thought processes over the next several days. First, what’s going on? And what should you do now? And next, and so on.

Please tweet and leave comments! My explanation of the initial steps tomorrow.

Pop Quiz: Jet Ski Injury

This post is for my readers located near large bodies of water!

Personal watercraft use exploded a decade ago, and they are still heavily used for recreation and vacation fun. However, speed and people don’t always mix well. Here’s an interesting case to ponder.

An 18 year old woman was the rear passenger on a jet ski traveling at a high rate of speed (of course). She fell off and was plucked out of the water by the driver. After riding for another 30 minutes, they headed to shore. A short while later, she began experiencing vague lower abdominal discomfort. This slowly progressed throughout the afternoon, becoming more severe.

She presents to your ED, looking uncomfortable and slightly ill. Here are some questions to ponder:

  • What injuries are you concerned about?
  • What diagnostics are appropriate?
  • If surgery is required, what are the appropriate approaches and procedures?

Please comment below, or tweet your thoughts. Answers tomorrow!

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!

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

Pop Quiz – Final Answer

Here’s some background info to go with the xray presented Wednesday:

  • Thin
  • Athlete
  • Epigastric trauma

Put these three together and you get a patient engaged in significant physical activity who was struck in the abdomen. If no pads are involved in the sport, the patient has little padding of their own.

This is a setup for pancreatic or duodenal trauma. This patient presented after being struck in the epigastrium by an elbow during a soccer game. It hurt, but wasn’t bad enough to stop playing. The following day, she was a little sore but felt bloated and started throwing up after breakfast.

In the ED, a CT was obtained. Here is a coronal view showing the distended stomach:

Axial views showed obstruction in the proximal 3rd portion of the duodenum, right over the spine:

An (unnecessary) contrast study was performed, which confirmed the pathology. Note the tapering and corkscrew appearance of the duodenal folds.

 

Final diagnosis: duodenal hematoma. This is a crushing injury from compression of the anterior abdominal wall against the spine. The third portion of the duodenum lies over the spine, as does the pancreas, so both are likely to be injured. The latter organ appeared normal on the CT.

Management of blunt duodenal hematoma is simple: wait on it. These will generally resolve quickly over the course of a few days. NG decompression is mandatory, since nothing will pass the obstructed area (saliva, gastic juice, and pancreatic effluent, which add up to 2L+ of fluid per day). In rare cases, parenteral nutrition may be needed if resolution time is approaching the one week mark or in smaller children. A surgical approach with drainage of the hematoma has a low but significant morbidity compared to just waiting. Athletes may return to play soon after recovery.