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....


Anonymous said...

Very good image and a great story to boot.

Anonymous said...

I enjoy reading your blog and look forward to each entry. Did you operate on him or transfer him?
That's a nice image.

shadowfax said...

Nice. It's a "one-glance" diagnosis. Haven't seen one in years (I'm happy to say).

rlbates said...

Nice image. Glad you don't see many of these.

Jeffrey Parks MD FACS said...

Anon 9:41-
I fixed the diaphragm and took out his pleen. He went to a level I center for the complicated pelvic fracture

Bongi said...

nice post. last one i did was for a high up government type. she lied about her medical aid and i was never paid. she also despised me in the ward afterwards which really pissed me off. so when i see this sort of scan i'm still filled with rage. ha ha.

Anonymous said...

Interestingly, it's not an uncommon injury in veterinary practice, where dogs and cats are often hit by cars. I guess I never thought about the proportional forces that would be required to have a person sustain that type of injury.

Anonymous said...
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shirla said...

Dear Buckeye: I came across your site the other day, and I know this is an older post of yours, but I do so hope you get to read mine..I am new to all of this. ( I know where have I been for the last 10 yrs right?)

Anyhow, it really struck me when you said that diaphragmatic ruptures were rare and that you hardly saw them. I was critically injured in a MVA in April 2005, (2 kids were racing and hit my friend and I head on) but I had that as one of my injuries, a ruptured diaphragm, my stomach and contents had pushed up through, collapsing my lung, I also had a burst fracture to my L3 vertebre, a TBI, and some other injuries.
It struck me, some of the things you said, about people having hernias and such after this kind of an injury, because at the time, I don't recall anyone ever telling me of this, but sure enough, I have had several issues with my stomach since the accident, and of course after my back surgery..then a hernia was found to be present in that scar!
When performing my back surgery..laminectomy?? i think it was called..i would have to dig out records, anyhow, they said the diaphragm was too weak to have anymore trauma to it, so the vascular surgeons cut around the side of me, opening me up for the neurosurgeons to place the cage, rods, etc. I had a surgery in 2008, to repair the hernia that was in that scar, but am in the process of another CT because it has ripped open again, or feels that way.
In January of this year, 2010, I spent a week in the hospital getting multiple tests performed while I knew something was wrong ( I think we know our own bodies best) but at any rate they came back to tell me that from the initial trauma to my stomach, where the small bowel meets the stomach, there exists adhesions there which are causing some blockage, but they didn't want to preform surgery to fix it, as that might increase the amount of adhesions and cause more problems. We already know that I have a hernia in the center of my stomach, (in line with where the exploratory laparotomy was done).

I have been surfing through your blogs and trying to find cases similar to mine, was extremely interested in the one where you had to take the ladies bowels out and unloop them...I think my insides might be, no, no let me say I KNOW my insides are all whacked out like that! I just wish I could find a doctor who would not bullshit me and would tell me what is really going on. I mean, my doctor is a great girl, she's awesome, but when it comes to this crap, she always has to send me to a surgeon, and the last ones I've had have all BS'd me.
funny how that all was about *&it.

I didn't mean it to be, that's why I wanted to write to you, you seem excited about figuring things out, fixing the problem. I want that. Need that. My daughter was only 10yrs old when this wreck happened, it took her mom away for too long. I sometimes still have very hard days, but I have worked very hard to get myself off of major amounts of meds and overcome things I thought I never would. Now this issue with my internal organs has come back to bite me in the ..and I need knowledge that I don't have.
Thanks for being on here!
OH Yeah, BTW, I am a buckeye too!