Case
#41 “He Didn’t Look Like That Before!” by Charlene Babcock Irvin, MD
As the incoming physician starting at 6:00 AM, you notice that the team leaving looks beat. During sign out rounds, after a very busy midnight shift (three gun shot wounds—two went to OR, another one admitted with fractured tibia going to OR shortly, and numerous trauma codes from blunt trauma), you notice that one patient doesn’t look very good. He was a ‘MVA, left upper quadrant (LUQ) pain awaiting CT, stable VS, labs OK’, per the sign out doc.
View from the door reveals a 25 y/o oriental man sitting up at 90 degrees on the cot, holding an emesis basin, diaphoretic, and tachypneic. He has very shallow breaths, and the monitor in the room reveals a HR of 110 (sinus), RR = 28-32, and blood pressure = 110/80. Oxygen saturation = 94% on RA.
Per the sign out team, he came in with a group of patients in the same MVA. Most don’t speak English very well, but the just of the story (per paramedics) is that the car was broadsided on the driver side at 30-40 MPH. This patient was a driver side passenger in the back seat, unbelted, and had no LOC. Initial history and physical exam was remarkable for LUQ pain/mild tenderness to palpation. He had a C-spine, CXR and Pelvis x-rays which were negative, and trauma labs were unremarkable. He continued to have LUQ pain to deep palpation, so a CT abd/pelvis was added on to his work up.
Per the sign out doc, the last time he saw the patient (about two hours ago) he did not look like this. The rest of the victims in the crash had already been discharged. He hasn’t gone for his CT yet because he refused to drink the contrast (this is the first the sign-out doc has heard about that). Per the nurse, he just throws it up after he drinks a few sips. The prescribed antiemetic (prescribed by resident) hasn’t helped. The nurse also tried twice to pass an NG tube (ordered by resident because patient couldn’t drink contrast), but after the second unsuccessful attempt, the patient refused further attempts.
You perform a quick bedside assessment:
When asked, ‘Are you having any problems breathing?’, he nods, yes. When you ask where it hurts, he points to his LUQ and left lower chest.
On exam, you note no sub-cutaneous air palpated. He is breathing rapidly with shallow breaths. He has decreased breath sounds at the left base. He refuses to lay flat for abdominal exam, so exam at 45 degrees reveals a thin muscular abdomen that is tender to palpation in the LUQ. There is no rigidity or guarding.
1. How useful is oral contrast for CT scanning after trauma?
2. What do you order now, and what are the possible causes for this patient’s symptom?
3. How often will you see delayed presentations of this type of injury?
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