A previously healthy, 25-year-old man is brought to the emergency department after falling approximately 3 m (10 ft) from a treehouse, landing on his left side. There was no loss of consciousness. The patient has left shoulder and left-sided chest pain, as well as abdominal pain. Blood pressure is 114/72 mm Hg and pulse is 116/min. Physical examination shows bruising to the left side of the chest wall and abdomen. Heart sounds are normal. There is sharp, left-sided chest pain with deep inspiration but equal breath sounds on both sides. The left costal margin and the left upper quadrant of the abdomen are tender to palpation. Range of motion of the left shoulder is normal. Portable chest x-ray is normal. Focused Assessment with Sonography for Trauma shows no pericardial effusion or significant intraperitoneal free fluid. Which of the following is the best next step in management of this patient?

Question

A previously healthy, 25-year-old man is brought to the emergency department after falling approximately 3 m (10 ft) from a treehouse, landing on his left side.  There was no loss of consciousness.  The patient has left shoulder and left-sided chest pain, as well as abdominal pain.  Blood pressure is 114/72 mm Hg and pulse is 116/min.  Physical examination shows bruising to the left side of the chest wall and abdomen.  Heart sounds are normal.  There is sharp, left-sided chest pain with deep inspiration but equal breath sounds on both sides.  The left costal margin and the left upper quadrant of the abdomen are tender to palpation.  Range of motion of the left shoulder is normal.  Portable chest x-ray is normal.  Focused Assessment with Sonography for Trauma shows no pericardial effusion or significant intraperitoneal free fluid.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d910_b35e_bc81_b981d12d51e3_MD0003_00 This patient with blunt chest/abdominal trauma has possible evidence of hemorrhage (eg, tachycardia), along with left upper quadrant (LUQ) pain and left shoulder pain that is likely referred (from blood irritating the phrenic nerve). This presentation is most concerning for splenic injury, one of the most common intraabdominal complications of blunt abdominal trauma (BAT). Patients with BAT who do not have frank peritonitis (an indication for immediate laparotomy) should undergo Focused Assessment with Sonography for Trauma (FAST). A positive FAST strongly suggests intraabdominal injury; however, a negative FAST does not rule it out because it can miss early bleeding or injuries (eg, bowel perforation) that do not produce detectable (eg, >200 mL) amounts of free fluid. For hemodynamically stable (eg, systolic blood pressure >90 mm Hg) patients with a negative FAST: High suspicion of intraabdominal injury, as in this patient with tachycardia, LUQ pain, and referred shoulder pain, should prompt contrast-enhanced CT scan of the abdomen and pelvis. Intravenous contrast "blush" (extravasation) can often identify active bleeding. Low suspicion of intraabdominal injury (eg, normal vital signs, nontender abdomen) can be managed with serial physical examinations, which are performed to rule out occult injury progression (Choice A). If operative intervention is required, every effort should be made to repair rather than remove the spleen, especially in children. If removal is unavoidable, postoperative immunization against encapsulated bacteria is mandatory. (Choices C and D) Splenic injury is often associated with left lower rib fractures. Although dedicated radiographs of the ribs are indicated (eg, costal margin tenderness), they are a lower priority than CT scan for ruling out active bleeding with likely splenic injury (eg, LUQ pain, referred left shoulder pain) and early shock (eg, tachycardia). Shoulder radiographs are also lower priority, especially because this patient has normal shoulder range of motion and his pain is likely referred (eg, blood irritating left phrenic nerve). (Choices E and F) Diagnostic peritoneal lavage may be considered for a negative/inconclusive FAST in hemodynamically unstable patients whose condition may clinically deteriorate during CT scan. Immediate exploratory laparotomy is indicated for peritonitis (regardless of hemodynamic status) or for a positive FAST in an hemodynamically unstable patient. Educational objective: Splenic injury, one of the most common intraabdominal complications of blunt abdominal trauma (BAT), should be suspected in any patient with BAT and evidence of hemorrhage. Hemodynamically stable patients with a negative ultrasound evaluation but high-risk features should undergo CT imaging. References: Splenic trauma: WSES classification and guidelines for adult and pediatric patients. (http://www.ncbi.nlm.nih.gov/pubmed/28828034) Radiology for trauma and the general surgeon. (http://www.ncbi.nlm.nih.gov/pubmed/28958364)

A Previously Healthy, 25-Year-Old Man Is Brought to the Emergency