Monday, June 23, 2008
Blunt force trauma
For the most part, the sort of cases you see at a suburban level II trauma center are rather banal. The old ladies who fall and come in looking like Rocky Raccoon. The guy who breaks a leg trying to clean the leaves from his gutters. The kid who falls of the monkey bars at recess. But every once in a while I see something interesting. The other day I was called about a young guy who had been ejected from his car at the time of a high speed MVC. He showed up tachycardic and hypotensive, but sort meta-stabilized after the initial resuscitation maneuvers were implemented. This enabled the ER doc to get him quickly to the CT scanner. When I first saw him he was still tach-ing away in the 130's and he looked pale and ghostlike. And he had peritonitis. I called the OR and got the blood infusing while I reviewed the images. For one thing he had a hilar splenic injury with massive amounts of hemoperitoneum. Hence the initial shock and peritonitis. The other interesting finding is portrayed in the image above....can you guess what it is?
Well, I'm not in the mood to be coy and let you play guessing games. It's a traumatic rupture of the diaphragm and it's not an injury seen very frequently, even in large tertiary care centers. The amount of blunt force necessary to cause the diaphragm to blow out is substantial and often these patients present with multiple injuries. No exception in this case. In addition to the splenic rupture, this kid also had a complicated pelvic fracture that ultimately had to be addressed at downtown level I trauma center.
Traumatic diaphragmatic injuries can be tricky to diagnose, especially when the injury is isolated. Diagnostic peritoneal lavage, laparoscopy, and thoracoscopy have all been utilized in recent years in algorithms to help facilitate the early identification of even small diaphragmatic tears. Isolated diaphragmatic lacerations from penetrating wounds are notoriously difficult to diagnose early; often the patient will show up years later with a symptomatic chronic diaphragmatic hernia. The repair itself is pretty straightforward. Several interrupted non-absorbable sutures will usually do the trick. You also have to worry about pleural contamination, especially if there has been a concomittant bowel injury. Lavage and drainage of the pleural space with a chest tube is sometimes warranted....