Yesterday, a child was brought to your ED who looked bad and felt bad, to the point you are convinced she has peritonitis. If the abdominal exam is convincing enough, there is no need for diagnostic imaging It would only serve to add time and radiation to the equation.
If you had really insisted on getting something like a CT, I would have told you that it just showed nonspecific distension and a small amount of free fluid. Helpful, right? And that at the age of 34 she would develop lymphoma for no apparent reason.
Your surgery team takes this patient immediately to the OR and finds this:
So now my questions are:
- What is going on here? What is this?
- What is really going on here? What’s the problem?
Please Tweet and leave emails or comments with your guesses. Discussion and answers tomorrow!
Here’s an interesting case for you to think about. A three year old female is brought to your ED with a three day history of abdominal pain which has been getting worse. She started vomiting yesterday, and hasn’t wanted to eat for two days. The child has been completely healthy until now. The parents deny any history of trauma.
On exam, the child appears to be ill. She has a distended abdomen bordering on rigidity, and is markedly tender. A FAST exam is performed, which shows a small amount of fluid only in the pelvis.
Here are my questions for you:
- What tests would you like to order?
- What is going on here?
Remember, this is the Trauma Professional’s Blog, after all!
Yesterday I posted an image of an unusual chest CT. The patient had been involved in a motorcycle crash weeks ago, and presented with new onset chest pain and weakness.
Exam of the chest showed a hint of diffuse swelling on the left side and moderate tenderness. Chest x-ray suggested a mild effusion on the left. I showed one slide of the CT yesterday, which showed a large amount of complex material in the chest wall. This is most likely a mixture of blood and clot.
Here is another slice of the CT that is more revealing:
Now you can see that there are multiple rib fractures present. While comparing the original and the recent scan, it is apparent that the fractures are more displaced on the recent one. Upon closer questioning the patient admits that he did fall down the day before the new pain and swelling occurred.
And by the way, he forgot to mention the fact that he had developed deep venous thrombosis and was taking warfarin! And also by the way, his blood pressures were becoming a bit soft.
I would consider this life-threatening bleeding! Crystalloid and blood resuscitate immediately. Reverse the anticoaguation quickly, using prothrombin complex concentrate (PCC, preferably 4-factor). Then send him to interventional radiology to see if there are any active bleeders that can be embolized. Finally, it’s off to the ICU to finish up the resuscitation and restore him to normal!
Here’s another one for you to figure out. Of course, I’ll give you minimal information and see what you can do with it.
A middle-aged male presents to your ED from home with left chest pain and weakness. There is a history of a motorcycle crash 6 weeks ago. Ultimately, a chest CT was obtained and here is a representative section:
Here are my questions:
- What’s going on?
- What should you do about it?
Leave a comment below or tweet your guesses. Answers tomorrow!
Yesterday, I presented the case of a young man with abdominal pain a few weeks after a splenectomy for trauma. One slice of the CT scan was presented, which showed pneumatosis in the wall of the cecum.
There have been some great comments from readers with some interesting reasoning, especially from StillChucklesandNP. Here’s another piece of the puzzle, yet another slice from the CT scan:
- What’s this?
- Any other important information?
- What’s the diagnosis and why?
- How do you treat it?
Looking forward to more tweets and comments! Answers tomorrow.