WIDI - A23) Blunt trauma

A23) Blunt trauma

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient presenting after trauma.
Review the DDx considerations in a patient presenting after trauma.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient presenting after trauma.

History

A 21-year-old male presents to a rural hospital ED following a high-speed motor vehicle accident. The patient complains of left upper abdominal, left shoulder, and neck pain. The patient denies any past medical history except for a recent EBV infection.

Physical Exam

BP: 89/60, HR 120, RR 19, Temp 98.6, O2 saturation 99%. General: Patient appears pale with clammy skin. Confused, sleepy, but arousable. Neck: C-collar in place. No stepoffs or tenderness to palpation on the cervical spine. No stepoffs or tenderness to palpation on the clavicles. Abdomen: Transverse and oblique areas of ecchymosis. Abdomen is nondistended but is tender to palpation. There is rebound tenderness.

Labs

Hgb: 8g/dL (nl: 13.8-17.2g/dL); Blood ethanol levels: 400mg/dL (nl <50mg/dL)

Provisional Diagnosis

Select the Dx you believe is most appropriate

Cervical fracture

Splenic laceration

Liver laceration

Clavicular fracture

This patient in hemorrhagic shock with a seatbelt sign, and peritoneal signs likely sustained a splenic laceration considering the left upper quadrant pain with referred shoulder and neck pain (Kehr’s sign).

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This patient who is in hemorrhagic shock requires emergent workup and management.

First Imaging Study

What is the first imaging study you will order?

MRI of abdomen

CT trauma series

CT chest, abdomen, and pelvis without IV contrast

A trauma series CT of the chest abdomen and pelvis with arterial and venous phases should be ordered to evaluate the spleen and other intra-abdominal organs.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

CT trauma series

There is free intraperitoneal air

Yes

There is no evidence of free intraperitoneal air.

There is evidence of splenic injury on the venous phase CT

Yes

On the venous phase, there are hypodense branching areas in the spleen representing splenic lacerations. There is also a subcapsular hematoma.

There is active extravasation of blood on the arterial phase CT

Yes

There is contrast blush present as contrast material pools around the spleen due to active extravasation of blood.

There is hemoperitoneum on the arterial phase CT

Yes

There is free intraperitoneal fluid, likely representing blood in this clinical context with splenic rupture. This is best seen on the sagittal view.

View Report

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Second Imaging Study

What is the next imaging study you will order?

Abdominal MRI

CT with oral contrast

None

No further imaging is needed as the diagnosis is confirmed with the trauma CT.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Cardiogenic shock

Hypovolemic shock

Obstructive shock

Distributive shock

The patient is in hypovolemic, or hemorrhagic shock due to rapid intraperitoneal bleeding secondary to grade 5 splenic laceration resulting in hemodynamic instability.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require immediate management as they are hemodynamically unstable.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 35-year-old male presenting with hemorrhagic shock secondary to a grade 5 splenic laceration. They will require a surgical consult for evaluation for emergent splenectomy given the hemoperitoneum with hemodynamic instability. The patient will require appropriate immunization for encapsulated organisms following splenectomy.

Lessons Learned:
- A splenic injury is likely to occur following blunt trauma to the abdomen such as motor vehicle accidents, sport injuries, or other violent causes such as fist blows or stabbings. Patients with recent history of EBV are at increased risk for spontaneous atraumatic rupture.
- The diagnosis should be suspected in someone who experienced blunt abdominal trauma, with either diffuse tenderness or tenderness in the LUQ, Kher’s sign (pain in left shoulder and neck worse with inspiration), and a seatbelt sign (abdominal wall ecchymosis).
- The first best diagnostic modality is a body trauma CT with IV contrast. It evaluates for active bleeding and presence of hemoperitoneum. Additionally, it can be used to determine the grading of the laceration, which can guide the treatment plan.
- High grade splenic lacerations (grades 4 and 5) in hemodynamically unstable patients likely require surgical intervention.
- This case emphasizes the importance of the ATLS protocol. Had this hemodynamically unstable patient undergone management per this protocol, they would have likely gone to surgery prior to CT scanning had the FAST exam shown free intraperitoneal fluid.

Socioeconomic Factors: Racial, ethnic, and socioeconomic disparities exist in trauma patients. For example, uninsured patients undergo less angioembolizations and are less likely to undergo nonoperative treatment. These patients also have higher mortality.

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Contributors:
Seyedeh Mehrsa Sadat Razavi, MS2 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator