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
Here’s some background info to go with the xray presented Wednesday:
- 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.
Here’s a new pop quiz for everyone. You’re all so good I’m not giving any hints on this one:
Now, the questions for you:
- What happened? Exact mechanism, please.
- What’s the pathology?
- What do you do about it?
Comment below or tweet to #TraumaPro
Well, it took me a month to figure out that one of my pop quiz answers was posted to the wrong area! The link provided with the tweet would have gotten you to it, but those who were following along on tumblr may have been mystified. Here’s the answer again.
Here’s a link to the original post/quiz.
So the question was to guess the exact mechanism of injury given the x-ray below.
The image shows a stomach bubble located in the left chest, indicating a left sided diaphragm rupture. In countries with left sided drivers, this is a classic injury from a t-bone type impact directly on the driver side door. The arm rest is driven into the driver’s flank, or on occasion the driver is partially ejected through the window. The impact raises abdominal pressure abruptly and can push the abdominal contents (typically stomach, followed by spleen) through the weakest area of the diaphragm.
Practical tip: These patients may present with tachypnea and decreased breath sounds on the left side. The usual reflex is to insert a chest tube, which is unneeded and won’t help in this case. What the patient really needs is an NG tube to help their breathing (and an immediate trip to the OR). So if you encounter this clinical combination plus a significant left sided impact (car crash, pedestrian struck), get a chest x-ray first if the patient’s condition will tolerate it.
And again, hats off to precordialthump for getting it exactly right!
All right, you’re good! Many people concluded that this was blunt trauma, and that there was something wrong with the diaphragm. Several people went so far as to say it was a motor vehicle crash.
Great so far! But take it one step further and tell me exactly what happened in this crash. You know, speed, direction, mass, all that physics stuff! Final answer tomorrow!