Overly Traumatic: A Teenager Elbowed in the Stomach
A 17 yo healthy M presents with abdominal pain and a syncopal episode several hours after getting elbowed in the stomach at a soccer game.
PMH: Intermittent asthma
ROS: Sore throat, cough and fatigue x 1 week.
VS: T 98.3 °F | HR 90 | BP 129/60 | RR 16 | SpO2 100%
Pale but comfortable and alert. Abdomen diffusely tender, guarding in the upper quadrants. Exam otherwise unremarkable.
RUQ: Free fluid in Morrison’s pouch & at the tip of the liver
LUQ: Free fluid in splenorenal recess & bowel floating in free fluid
Transverse Bladder: Large amount of fluid & clotted blood anterior to the bladder
Click ahead to reveal diagnosis
Two cases this week! Thank you to Dr. David Kaplan for submitting the first case, while the second case was one seen by myself and Dr. Paul Cheung.
58 y/o male sustained blunt force trauma to the lateral aspect of his right knee. On exam, there is a mild right knee effusion, but no obvious deformities. Pain with ROM. Neurovascularly intact. No ligamentous laxity appreciated. X-rays of the right knee are obtained:
22 y/o male sustained a gunshot wound to the right knee. On exam, there is an entrance wound on the posterior-lateral aspect of the knee, but no exit wound. There is pain with ROM of the knee and a mild effusion is appreciated. No obvious deformities. Neurovasculary intact. No ligamentous laxity appreciated. Initial plain films demonstrate the bullet lodged in the mid-thigh. Physical exam findings and x-rays of the right knee:
Given concern for an open joint, an aspiration is performed prior to irrigation, and the following aspirate is obtained:
What’s the diagnosis?
Part of our recurring ’52 Articles’ series exploring landmark articles in Emergency Medicine, inspired by the ALiEM blog’s index project,
- Over 23 years 950 patients underwent post injury thoracotomy at Denver Health Medical Center and overall survival was noted to be 4.4 percent with 3.9 percent surviving functionally intact.
- Using various assumptions for cost analysis the authors concluded that “the benefit-charge ratio was strongly in favor of performing EDT [emergency department thoracotomy] at 5.6:1, it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime.”
Emergency department thoracotomy remains a hotly debated procedure within the scope of emergency medicine. Not only is it a resource intense process that potentially places providers at increased risk for blood borne infections, but it is also one whose utility has been questioned given the limited success rate of meaningful patient outcomes. The authors of this study reviewed a cohort of consecutive trauma patients presenting to a level I hospital in Denver, CO in hopes of clarifying not only the costs as well as the utility of the procedure. The authors in this study reported “neurologically intact survival at time of discharge” as one of the study outcomes; however, it does not appear that any patients had post-hospitalization follow up to evaluate for any future changes. Continue reading
1. The final Canadian C-spine Rule comprises three questions:
A.) Is there a high-risk factor that mandates radiography such as: age≥65, dangerous mechanism, or paresthesias in extremities?
B.) Is there any low-risk factor that allows safe assessment of range of motion such as: simple rear end MVC, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness?
C.) Is the patient able to actively rotate neck 45° to the left and right?
- The Canadian C-Spine Rule was tested on a convenience sample of 8,924 alert and stable trauma patients in 10 Canadian emergency departments with 151 cases of clinically significant C-spine injury and proved to have a sensitivity of 100% (95% CI: 98-100%) and a specificity of 42.5% (95% CI: 40-44%).
Less than three percent of trauma series yield a positive result.
According to the data compiled by the researchers in the Canadian CT Head and C-Spine Study the use of C-spine radiography is quite variable among emergency physician providers based on local culture and the overall cost of C-spine radiography is in the multi-millions. Their research demonstrated that less than three percent of trauma series yield a positive result. Continue reading
This is the first in a blog series that will explore landmark articles in Emergency Medicine.
- Patients meeting the following five simple clinical criteria are safe to clear without cervical spine imaging following blunt trauma:
- No focal neurologic deficit
- Normal alertness
- No intoxication
- No midline posterior bony cervical spine tenderness, and
- No painful distracting injury
- The sensitivity and specificity of the NEXUS criteria for detecting low probability injury and avoiding unnecessary imaging was 99 and 12.9 percent respectively, with a negative predictive value of 99.8 percent for the detection of clinically significant injuries.
Level of evidence: 1 (Prospective cohort trial)
Based on the ACEP grading scheme for diagnostic questions the NEXUS trial receives a class of evidence rating of 1.
Blunt trauma is a frequent cause of emergency department visits. However, the overall prevalence of cervical spine injury is generally only between 2-4% (2.4% in the NEXUS cohort). The goal of the NEXUS group was to create a simple clinical tool with which to risk stratify patients following blunt trauma, thereby reducing unnecessary cervical spine imaging and subsequently improving patient care through cost-reduction and a decrement in the downstream oncogenic risk secondary to radiation exposure. Continue reading