A 50-year-old male presents as a trauma following a motor vehicle accident. He has a Glasgow Coma Scale (GCS) score of 15 and is complaining of abdominal pain. His vital signs are as follows:
On examination, he has significant tenderness to palpation over his mid-abdomen, and an ecchymosis is present in a bandlike distribution. A FAST examination is negative. He is taken for a CT scan that reveals no evidence of solid organ injury, no free air, and moderate free fluid on the pelvis and a mesenteric hematoma. He continues to have significant pain on abdominal examination.
What is the most appropriate next step in management?
Correct Answer: A
Gastrointestinal injury following blunt abdominal trauma occurs in an estimated 3.1% of patients being evaluated followed blunt abdominal trauma. Most commonly, these injuries are seen the following motor vehicle collisions, where the mechanism involves crushing of the bowel between solid structures (ie the spine and a steering wheel). The definitive diagnosis of hollow viscus injury is made by abdominal exploration, with physical examination and CT imaging being used to help make the decision to go to the operating room. The patient presented above has a concerning abdominal examination, which in combination with the CT findings of free fluid in the absence of solid organ injury, is concerning for a hollow viscus injury. Although the finding of free intraperitoneal air on CT imaging has high specificity for a hollow viscus injury, the lack of pneumoperitoneum on imaging does not rule out a diagnosis of hollow viscus perforation. The next appropriate step would be to obtain urgent surgical consultation and proceed with exploratory laparotomy (Answer A). Admission to the floor for serial examinations and administering IV narcotic pain medication both fail to address the underlying diagnosis and could lead to life-threatening complications (Answer B, D). CT scans are more sensitive for the identification of free intraperitoneal fluid, thus there is no benefit at this point of repeating a FAST ultrasound examination (Answer C). There is no role here in placing a nasogastric tube for gastric decompression (Answer E).
References:
A 55-year-old female presents to a Level 1 Trauma center following a motor vehicle collision with CT findings of an AAST (American Association for the Surgery of Trauma) Grade III liver laceration with a small “blush” identified by radiology. The patient has a GCS score of 15, is hemodynamically stable, and has only mild abdominal discomfort on examination.
What is the most appropriate next step in the management of this patient?
Correct Answer: D
The liver is the most commonly injured abdominal organ in the setting of blunt abdominal trauma. Historically, liver injuries required operative intervention but based on multiple studies, current consensus recommendations have shifted to the nonoperative management of liver injuries in the hemodynamically stable patient who do not otherwise have an indication for surgical intervention (Answer D, E). Additionally, these patients, should they require an intervention, may benefit from selective vascular embolization via Interventional Radiology, rather than operative intervention. When nonoperative management is pursued, the patient requires close hemodynamic monitoring in a critical care unit as well as serial abdominal examinations should their examination evolve (Answer A). While it is important to maintain adequate access for large volume resuscitation should need arise, there is no role for the prophylactic administration of large volume crystalloid in the trauma patient (Answer B). There is no clinically relevant role for monitoring LFTs in the setting of known blunt hepatic injury (Answer C). Patients who are hemodynamically unstable or who have diffuse peritonitis on examination differ greatly in their management, as they do require urgent operative intervention.
Reference:
A 27-year-old male presents to the Emergency Department after sustaining a fall from a third-story balcony. On primary survey, the patient is noted to have an intact airway and bilateral, symmetric breath sounds. His pulses are palpable, but weak, and his initial vital signs are as follows: HR 50, BP 80/40, Sat 100% on room air. EMS reports that he was given 3 L crystalloid in the field for persistent hypotension without significant improvement in his vital signs. On examination, he has no obvious source of bleeding, and he is noted to have decreased sensation at the level of the mid chest extending to bilateral lower extremities with 0/5 strength bilaterally. All of the following are appropriate in the initial evaluation and management of a patient with suspected neurogenic shock EXCEPT?
Neurogenic shock is a form of distributive shock that is seen in patients with severe traumatic brain injury and spinal cord injury (cervical and upper thoracic spine). It differs from spinal shock in the sense that not all spinal cord injuries cause a distributive shock picture, and rarely is it seen in spinal cord injuries below the level of T6. In a trauma patient presenting with signs/symptoms concerning for neurogenic shock, it is important to rule out concomitant causes of shock including hypovolemic shock (hemorrhagic and nonhemorrhagic), cardiogenic shock, obstructive shock, and other forms of distributive shock (Answer A). Initial management involves completing a thorough physical examination, close hemodynamic monitoring, initiation of resuscitation with crystalloid or blood products as indicated, and initiation of vasopressor therapy if hypotension persists despite adequate resuscitation (Answer C). Until imaging is obtained that can rule out an unstable spine injury, it is pertinent to maintain Cervical spine stabilization with use of a C collar and spinal precautions to avoid worsening an injury (Answer B). Initial imaging with CT is indicated to evaluate the spine as well as any other concomitant injuries, with the need for further imaging being dictated by a spine specialist. It is important to note though that imaging of the head and C spine is inadequate given that upper thoracic spine injuries (above T6) can also cause neurogenic shock and its sequelae (Answer D). Following diagnosis, admission to a SICU is recommended for continued monitoring and treatment given the potential life-threatening complications including cardiovascular collapse and respiratory failure (Answer E).
A 45-year-old female is hypotensive following a motorcycle accident. She is taken to the trauma bay where she is noted to be hypotensive. An abdominal FAST examination is negative for intraperitoneal fluid. On examination, she has no abdominal tenderness and her pelvis is grossly deformed. A chest radiograph is obtained that demonstrates no obvious hemothorax, and a pelvis film shows a severe open book deformity. In addition to resuscitation, what is the most appropriate next step in management of this patient?
Correct Answer: C
This patient is presenting after a motorcycle accident with hypotension and an obvious pelvic deformity. In addition to obtaining large bore peripheral access and initiating resuscitation, it is recommended that a temporary pelvic binder is applied to reapproximate the pelvic ring (Answer C). Emergent Orthopedic surgery consultation allows for the evaluation for external pelvic fixation in addition to ongoing hemorrhage control maneuvers. As in any trauma patient presenting with hypotension, it is important to obtain adequate intravenous access for resuscitation. If peripheral access cannot be obtained, central venous access is an option, although in a patient presenting with a pelvic fracture the femoral veins should be avoided (Answer E). Hemorrhage associated with pelvic fractures is most commonly from the sacral venous plexus, although occasionally an arterial source may be involved. Pelvic angiography by Interventional Radiology allows for localization of the source of bleeding, as well as intervention in the form of selective embolization or internal iliac embolization, which decreases overall pelvic inflow. It would be inappropriate to send this patient to the CT scanner or the ICU without first addressing the hypotension and presumed ongoing hemorrhage (Answer B, D).
A 4-year-old male is brought to the emergency department by his parents after swallowing a coin. On presentation, the child has a cough but otherwise appears comfortable, interacting with his parents and with oxygenation saturation readings 100% on room air. A plain radiograph is obtained that shows a radiopaque foreign body in the proximal right mainstem bronchus.
What is the most appropriate next step in management of this patient?
Correct Answer: E
The child above is presenting after a witnessed aspiration event of a small object with signs of a partial airway obstruction. In children presenting with signs of a complete airway obstruction, including severe respiratory distress, cyanosis, and altered mental status, attempts at object dislodgement can be made including back blows, chest compressions, and the Heimlich maneuver. In cases of partial obstruction in the stable patient, these maneuvers should be avoided for fear that they may convert a partial obstruction to a complete airway obstruction (Answer B). In the stable patient, a CT scan can provide additional information if the diagnosis is unclear, but in the case mentioned above, no additional necessary information is needed before therapeutic intervention (Answer A). The next appropriate step in management of this patient would be to proceed to the operating room for a flexible and/or rigid bronschoscopy for evacuation of the foreign body and visual evaluation of the airways (Answer C). The majority of foreign body ingestions/inhalations occur while under adult supervision, and education may be helpful in reducing the incidence; this is not the most appropriate next step in management of this child (Answer D). An upper GI swallow does not add any value to the management of this patient (Answer C).
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