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

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


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
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?

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?

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.
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.

Watch our video

View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

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?

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?

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