Tag Archives: pop quiz

Pop Quiz! DPL

Ahh, remember the good old days of DPL? Probably not! But here’s an interesting case that presents a real diagnostic dilemma. Hint: this case occurred B.F. (before FAST) and B.G.C.T. (before good CT). That’s why we used DPL!

The patient was a middle aged woman who was involved in a car crash. She had mild, diffuse abdominal pain and a faint seat belt sign. She was prepared for DPL in the ED. It was performed using percutaneous (Seldinger) technique with a fenestrated catheter. Placement was in the usual position, 2cm below the umbilicus in the midline.

The aspirate was negative. A liter of LR was infused  and the bag was then lowered to drain. About 600 cc of clear amber fluid returned easily.

However, on closer inspection, a small amount of sediment could be seen in the tubing.

What the heck!? What’s going on and what, if anything, do we need to do?

Post your guesses and comments below, or Tweet them. I’ll provide hints over the weekend, and the answer on Monday.

Source: Personal archive. Not treated at Regions Hospital

Pop Quiz! The Answer!

Time for the answer! There were lots of well thought out guesses, and a few correct answers. 

Here’s the story. This is a young male who presented in the trauma room with a small penetrating injury on the lateral aspect of his right arm, and another one just medial to the top of the scapula. If you look at first image last Wednesday, you can see an obvious humeral fracture, a not so obvious lack of lung markings, and a few tiny metallic foreign bodies (bullet fragments picked up by Canuck ER MD, injuries surmised by Kurt Rubach, paramedic). I provided a zoomed in view on Thursday to make them a little more obvious.

What I didn’t tell you (besides the fact that there were bullet holes) was that there were no pulses in the arm. The patient was hemodynamically stable, so after evaluation in the ED and insertion of a chest tube, he was taken to angio to evaluate the injury location. Unlike many penetrating injuries where the location is obvious, this was a deep mediastinal hit possibly involving Zone I of the neck (thanks Traumahst). Angio was selected because this was in the days before chest CT.

This shows a cutoff of the right subclavian artery. The patient was taken to the OR for sternotomy with a right neck extension and resection of the medial third of the clavicle (see Friday’s xray). The injury was successfully repaired with good return of function, and some residual hemothorax. He was discharged home in a week.

Bottom line: This one was tough because I didn’t give you much of what trauma professionals really need: clinical context. An isolated xray without a clinical history is not enough. It’s very easy to see things that really aren’t there and end up on a wild goose chase. Keep that in mind the next time you expect your radiology colleagues to come up with miracle diagnoses while sitting in a darkened room. Give them the whole story, or have them pop over to the ED to see for themselves.

Pop Quiz: The Answer!

There were lots of interesting guesses regarding this photo! Some were very creative, and thought I might be throwing a curve ball. Alas, this was much more straightforward.

What you see is a pair of wounds located just at or slightly above the iliac crest on the right side. If you look carefully, you will see a powder burn around the anterior wound, indicating a close range gunshot. So this would appear to be a run of the mill gunshot to the abdomen; just run to the OR, right?

Not so fast! There are some nuances when dealing with this type of wound. The first things to look at are the vital signs. If they’re not stable, then there is major bleeding present and the patient needs to go to the OR now. Next, do a good exam. As always, stick to the ATLS protocol to make sure you’re not focusing on the abdomen and missing other significant findings. If the abdominal exam is abnormal (tenderness, peritoneal signs) there is either bleeding or contamination and once again it’s time to go to OR. About 98 times out of 100, that’s where you’ll be with a picture like this.

However, if you’ve gotten to this point with none of the above, there is the small possibility that this might be a tangential injury. The flanks (“love handles”) tend to be fairly fatty in some men, especially the obese. And since most civilian gunshots are low velocity, there is less likelihood of deeper injury from blast effect. Local wound exploration is tough in this area due to the amount of fat and the deeper musculature. 

My preferred method for evaluating this (rare) type of patient is a quick CT scan of the abdomen and pelvis. The pelvic part is important, because you are looking for obvious penetration and blood in the pelvis. If you see either, it’s time to head to the OR. Very rarely (on the right side) you may see a contusion or superficial laceration of the liver, meaning that there was penetration. However, if there is no possible way the bowel was injured, it is acceptable to closely observe the patient.

Oh, and the board? Back in the day before everything was made of plastic, they actually made backboards out of fairly nice wood!