Intern Report 6.10

Case Presentation by Dr. Sean Michael

Chief Complaint: “my stomach is killing me”

History of Present Illness :

57-year-old man with history of COPD and remote history of breast and testicular cancer who presents to the ED approximately 72 hours after an alleged assault in which he was struck with a bat multiple times in the left flank. He sought care on the day of the assault and had a negative urinalysis, chest x-ray, and plain films of the right hand and wrist and T- and L-spine. He reported that his pain had improved considerably while in the ED, and he was discharged home.

He returns today complaining of severe epigastric and left flank pain as well as multiple episodes of nausea and vomiting that began when he woke up this morning. He denies trauma in the interim and has otherwise been well with no recent illness, fever, chills, diarrhea, dysuria, or hematuria. His flank pain radiates to the left groin and is “sharp” and severe. It has been worsening since the onset this morning. He’s had no relief with ibuprofen 800 mg and Norco, which he was prescribed during his last ED visit.

Review of Systems : Negative except per HPI

Medications: albuterol, Norco, ibuprofen.

Medical history: remote history of breast cancer, remote history of testicular cancer, COPD

Surgical history: bilateral mastectomy (remote)

Social history: Denies alcohol use, current tobacco use, and illicit drug use

Physical Examination

Vital signs:  T 35.9, BP 143/99, HR 85, RR 18, SpO2 99% on room air, BMI 17.8

General:  Alert, anxious, diaphoretic. Ill-appearing and looks rather uncomfortable.

Skin:  Normal color for ethnicity.  Cool, diaphoretic.

Head:  Atraumatic

Neck:  Normal active ROM.  No tenderness, step-off, or deformity.  No JVD.

Eye:  PERRL, EOMI. Normal conjunctiva.

ENT:  Dry oral mucosa

Cardiovascular:  Regular rate and rhythm.  Normal S1 and S2. No murmur.  No edema.  Radial pulses strong and symmetric. Extremities well-perfused.

Respiratory:  Lungs are clear to auscultation bilaterally.  Respirations are non-labored. Symmetrical chest wall expansion.

Chest wall:  No tenderness, ecchymosis, deformity, or other evidence of trauma.

Abdomen:  Significant voluntary guarding. Upon focused relaxation, he has significant epigastric and left upper quadrant tenderness as well as left CVA tenderness. He has pain referred to the epigastrium upon palpation elsewhere in the abdomen. He has intense pain with gentle back and forth movement of the abdomen and with tapping on his heels.

Musculoskeletal:  Moving all extremities spontaneously, no deformity or evidence of trauma

Neurological:  Alert and oriented to person, place, time, and situation.  No focal neurological deficit observed.  Face symmetric. Grossly normal sensation, motor function, and speech.

 

IV access was established, and labs were sent including CBC, chemistries, coags, type and screen, LFTs, amylase, lipase, serum alcohol, UDS. He was bolused with IV normal saline and given IV morphine for pain control.

12-Lead EKG:

6.10 ECG

Chest X-Ray (upright): Old right-sided rib fractures but no acute cardiopulmonary abnormality. Mild hyperinflation. No evidence of pneumoperitoneum.

Bedside FAST exam was performed.

US-LUQ

Questions:

1. Based on the case information provided and this ultrasound image of the patient’s left upper quadrant, which of the following is the most appropriate next step in management?

A. Urgent consultation to urology

B. Urgent consultation to general surgery

C. CT abdomen/pelvis with PO and IV contrast

D. Urinalysis with microscopic exam

2. After administration of 2 liters of IV normal saline and 0.1 mg/kg morphine IV, the patient becomes hypotensive and complains of lightheadedness. Which of the following is the most appropriate next therapy?

A. IV crystalloid

B. Blood products

C. Naloxone

D. Diphenhydramine

 3. For which of the following patients is bedside FAST exam most appropriate and clinically helpful?

A. 40 year-old woman ejected from her motorcycle after a collision, HR 94 and BP 142/89

B. 23 year-old man with a gunshot wound to the right upper quadrant, HR 128 and BP 94/56

C. 28 year-old woman involved in a motor vehicle collision who has a “seat belt sign,” HR 92 and BP 132/78

D. 37 year-old male pedestrian struck by a vehicle at 30 mph, HR 112 and BP 102/60

 

Answers:

  1. B
  2. B
  3. D

 

Course in the ED:

In this case, bedside FAST exam was actually the first imaging obtained (17 minutes before the portable chest x-ray).

RUQ (positive for free fluid in the hepatorenal space and perihepatic areas):

US-RUQ

 

Suprapubic-transverse (fluid in the lumen of the bladder with a significant amount of free fluid in the pelvis):

US-PelvisTrans

 

Suprapubic-sagittal (same as above):

US-PelvisSag

The subxyphoid view was negative for pericardial effusion and is not shown.

The LUQ view (shown in question 1) was positive for a small amount of free fluid in the splenorenal space and much more free fluid in the perisplenic area. An urgent consultation was placed to general surgery (answer B). The patient was also crossmatched for 4 units of packed red blood cells and consented for transfusion, if necessary. After evaluating the patient, the surgery resident requested that we obtain a stat CT of the abdomen and pelvis with IV contrast. The patient remained hemodynamically stable and went to CT uneventfully.

Axial image through the mid-spleen:

Axialj

Sagittal image through the spleen and kidneys:

Coronalj

 

The CT demonstrated a grade 3 splenic laceration with significant hemoperitoneum and a large subcapsular hematoma, likely with a small amount of active extravasation.

While surgery was staffing the patient, the patient began having worsening discomfort and became more agitated. He became hypotensive to the mid-70s systolic with heart rate 110-115 and respiratory rate 30. At this point, the patient had already received at least two liters of crystalloid, and he was transfused with two units of packed red blood cells (question 2, answer B). Central venous access was obtained, and the patient was taken emergently to the operating room by general surgery.

He underwent exploratory laparotomy and was found to have a grade 4 splenic rupture with 3000 mL of blood in the abdomen and a grade 1 small bowel mesenteric hematoma in the jejunum. He received further pRBC transfusions in the OR, as well as Cell Saver autologous transfusion. He underwent splenectomy and was transferred to the SICU. His postoperative course was uneventful, and he was discharged home on post-operative day #4.

 

Discussion: imaging in blunt abdominal trauma

Emergency physicians are confronted with a broad spectrum of presentations of abdominal trauma, both blunt and penetrating. We also have at our disposal a variety of imaging options to evaluate and diagnose these injuries. As with any diagnostic test, however, it is important to understand the performance characteristics in order to appropriately select the right test in a given clinical situation.

Ultrasound:

Focused Abdominal Sonography for Trauma (FAST) is commonly performed as part of the assessment of all major trauma patients, but we sometimes rely on the result as being “black and white” (no pun intended) without fully understanding how to use the exam to inform the clinical picture. Conversely, some physicians discount the utility of ultrasound in the trauma patient altogether.

FAST is a triage tool, not a screening test. In other words, a negative FAST exam is not adequately sensitive to rule out intraperitoneal free fluid (pooled sensitivity 82%; -LR 0.26, 95% CI 0.19-0.34)(6). A positive FAST exam, however, is more accurate than any history or physical examination finding in diagnosing intra-abdominal injury (+LR 30, 95% CI, 20-46)(6). Thus, it is most clinically useful to rule-in injury, rather than to rule it out.

Evidence-based clinical practice guidelines from the American College of Emergency Physicians (ACEP), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Radiology (ACR) are in agreement that FAST is the imaging modality of choice for hemodynamically unstable adult blunt abdominal trauma patients (1,2,4). In the setting of hemodynamic instability, a positive FAST convincingly rules-in intra-abdominal injury requiring operative intervention (1,2,4,5,6,7). A negative FAST, however, does not rule-out an abdominal injury.

Interesting Sidebar (compiled from reference 6):

Finding

Likelihood Ratio for Intra-abdominal Injury (95% CI)

Positive FAST 30 (20-46)
Base deficit less than -6 mEq/L 18 (11-30)
Presence of seat belt sign LR range 5.6-9.9
Rebound tenderness 6.5 (1.8-24)
Hypotension 5.2 ( 3.5-7.5)
Abdominal distention 3.8 (1.9-7.6)
Abdominal guarding 3.7 (2.3-5.9)
Absence of tenderness to palpation 0.61 (0.46-0.80)
Negative FAST 0.26 (0.19-0.34)

In the hemodynamically stable patient, ultrasound still provides useful information, but it’s clinical application is different. Because a positive FAST rules-in intra-abdominal injury, further evaluation is required to determine whether the stable patient requires operative intervention. In one prospective trial, the use of FAST in these patients reduced time-to-surgery by 109 minutes (64% reduction) and also reduced hospital length of stay, complications, and cost (5). Stable patients with a positive FAST should undergo CT (1,4). Depending on the pre-test probability of intra-abdominal injury, stable patients with a negative FAST may be candidates for observation, rather than immediate CT (4). The use of ultrasound for the evaluation of stable patients with blunt abdominal trauma has been shown to decrease CT utilization without deleterious effects on patient outcomes (5).

Of the patients described in question 3, the patient with unstable vital signs and blunt trauma (answer B) is most likely to benefit from FAST. There is a role for FAST in the stable blunt trauma patients (answers A and C), but less so than for the unstable patient. The hemodynamically unstable patient with penetrating abdominal trauma (answer D) requires emergent operative intervention, and FAST is very unlikely to add meaningful information (3,7).

CT:

The same authorities described above also agree that there is rarely a role for CT in the unstable trauma patient (1,2,4). For the stable patient, the preferred imaging modality is CT of the abdomen and pelvis with IV contrast, which enables detection of active bleeding (1,2,4,6). The American College of Radiology makes it clear that “CT evaluation of the abdomen and pelvis for blunt trauma does not require the use of oral contrast” (1). ACEP makes a level B recommendation that “oral contrast is not required in the diagnostic imaging for evaluation of blunt abdominal trauma” (question 1, answer C)(2). This includes the initial scan for patients suspected of having bowel injury (2).

CT has the advantage of better defining organ injury and identifying patients who may be candidates for nonoperative management of solid organ injuries (1). This is part of the rationale for obtaining a CT in stable patients with a positive FAST. It is possible to have intraperitoneal free fluid as a result of an injury that can be managed more conservatively. In addition, CT has the ability to visualize the retroperitoneum and vertebral column (1). While it is much more sensitive for solid organ injury than ultrasound, CT is not sufficiently sensitive to rule out some pancreatic, diaphragmatic, bowel, and mesenteric injuries (1). Therefore, patients with suspicion of intra-abdominal injury but negative CT should be observed for clinical changes that may suggest an occult injury (4).

 

Summary:

  • No imaging test is sufficiently sensitive to exclude clinically meaningful intra-abdominal injury in the setting of blunt abdominal trauma.
  • FAST is most useful when it is positive in a hemodynamically unstable blunt trauma patient.

 

References:

  1. American College of Radiology. “ACR Appropriateness Criteria: Blunt Abdominal Trauma.” (http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BluntAbdominalTrauma.pdf). Accessed February 3, 2013.
  2. Diercks DB, Mehrotra A, Nazarian DJ, et al. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med. 2011;57(4):387–404.
  3. Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68(3):721–733.
  4. Hoff WS, Holevar M, Nagy KK, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: the East practice management guidelines work group. J Trauma. 2002;53(3):602–615.
  5. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227–235.
  6. Nishijima DKD, Simel DLD, Wisner DHD, Holmes JFJ. Does this adult patient have a blunt intra-abdominal injury? JAMA. 2012;307(14):1517–1527.
  7. Offner P. “Penetrating Abdominal Trauma Treatment & Management.” eMedicine website. (http://emedicine.medscape.com/article/2036859-overview). Accessed February 3, 2013.

3 Responses

  1. 1. My answer is . This is based on the fact the pt is hemodynamically stable and I think has a low-gerade splenic rupture (<3). But honestly, B and C are both right here. This is a blunt trauma patient who is hemodynamically stable with a positive FAST. The next step is a CT scan of the abdomen and pelvis but you also must consult general surgery quickly. If the CT shows a surgical belly they are going to the OR, but it is prudent to get surgery on board before these results so they can familiarize themselves with this patient and see them in a timely manner regardless of the results…you know he's not going home, you know he's not going to medicine. Call surgery.

    2.

    3. is my answer because it is the only one in which the FAST may acutely change the management. A is a multi trauma patient, is she having abdominal pain? Do we have reason to suspect abdominal injury. A FAST is definitely warranted and clinically useful, but if all her pain is in her distracted fracture in the LLE, not so much, and even if positive she will likely go to CT before OR. For C, she is hemodynamically stable so she can go to CT. Anyone with a seatbelt sign is getting a CT of the belly whether the FAST is positive or negative. So I argue, is it really clinically helpfu to get a FAST? It's positive, so what she is stable, still going to CT. For D, another possible poly trauma, have no idea where he looks injured, a little bit more unstable, but if FAST negative and no signs of abdominal trauma or bleeding into belly, I don't think he is so unstable that he would fly to OR for ex lap until more info obtained. I think you would start looking elsewhere, maybe pelvis. FAST positive though, he likely goes to OR, especially if those vitals get a little worse.

  2. 1.) 2.) 3.) (although A has a mechanism for significant injury as well, and even though vitals are stable I think a FAST exam would be appropriate and clinically helpful)

  3. Tim pointed out that I switched B and D in the explaination for question 3. It should read:

    Of the patients described in question 3, the patient with unstable vital signs and blunt trauma (answer ***D***) is most likely to benefit from FAST. There is a role for FAST in the stable blunt trauma patients (answers A and C), but less so than for the unstable patient. The hemodynamically unstable patient with penetrating abdominal trauma (answer ***B***) requires emergent operative intervention, and FAST is very unlikely to add meaningful information (3,7).

    Thanks, Tim. Sorry for the confusion!

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