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Foundations Case Presentation

Foundations I Course:

Case 96

Presentation Author: Drs. David Brown and Stephen Rogers

Presentation Editor: Drs. Zach Grant and Marshall Howell

Last Revised: Fall 2024

Creative Commons ©Foundations of Medical Education, Inc.

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Case Home Base

ECG

Labs

X-Ray

CT

US

Critical Actions

Initial Vitals

Repeat A

Repeat C

Teaching

Repeat D

Repeat B

16 yo M presents after football injury

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Initial Presentation

HR: 120 BP: 90/62 RR: 16 T: 36.3 ̊ C

Sat: 97% on RA Wt: 70 kg

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16 yo M presents after football injury

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Reevaluation A

HR: 115 BP: 89/58

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16 yo M presents after football injury

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Reevaluation B

HR: 130 BP: 80/52

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16 yo M presents after football injury

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Reevaluation C

HR: 110 BP: 95/60

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16 yo M presents after football injury

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Reevaluation D

HR: 140 BP: 75/47

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16 yo M presents after football injury

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General Lab Results

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Special Lab Results

Lactate: 3.2

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*All other labs are NORMAL

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ECG

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Sinus tachycardia, otherwise normal

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US - RUQ

Figue 96.3A - RUQ View

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US - LUQ

Figue 96.3B - LUQ View

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US - Suprapubic

Figue 96.3C - Sagittal Suprapubic View

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US - Subxiphoid

Figue 96.3D - Subxiphoid Cardiac View

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US - FAST Exam

Video 96.4 - POCUS FAST (RUQ, LUQ, and Pelvis)

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Video 96.5- POCUS FAST (Subxiphoid Cardiac view)

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CXR (figure 96.1)

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XR Pelvis (figure 96.2)

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CT

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Nurse: “Are you sure this patient is stable enough to come to the CT scanner?”

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Case Diagnosis:

Splenic Rupture from Blunt Abdominal Trauma

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Critical Actions:

  • Obtain 2 points of IV access
  • Provide IV fluids
  • POCUS Fast Exam
  • Early uncrossed pRBC infusion
  • Emergent Trauma Surgery Consult

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Blunt vs. Penetrating Abdominal Trauma

  • Blunt Trauma
    • Negative CXR & FAST -> CT and Observation
    • Positive Fast + Stable Vitals -> CT
    • Positive Fast + Unstable Vitals -> OR
    • Free Air on CXR -> OR
  • Penetrating Trauma
    • GSW to Abdomen -> OR
    • Stab Wound to Abdomen
      • Stable Vitals + no peritonitis -> CT
      • Unstable Vitals, +FAST and/or signs of peritonitis -> OR

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Blunt Abdominal Trauma Algorithm

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Trauma Patient

Stable

Unstable

FAST Positive

FAST Negative

FAST Positive

FAST Negative

Resuscitate +/- Pelvic Binder and CT Scan

CT Scan

+/- CT Scan and Observation

Operating Room

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POCUS Pearls

  • RUQ “Morrison’s Pouch” - most sensitive view for peritoneal free fluid
  • LUQ - fluids tends to collect between spleen and diaphragm
  • Pelvis - Obtain transverse and longitudinal views
  • SX or PSL - Assess for effusion/tamponade
  • E-FAST - includes bilateral lung sliding

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PECARN Rule For Pediatric Blunt Abdominal Trauma

  • Sensitivity of 99%
  • No need for CT if all of the following are true
    • No evidence of abdominal wall trauma or seatbelt sign
    • GCS >13
    • No abominable tenderness
    • No evidence of thoracic wall trauma
    • No complaints of abdominal pain
    • No decreased breath sounds
    • No vomiting

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References

Foundations Case #96

Case Author(s): Dr. Amanda Barrett Whipple

Ultrasound Content: Dr. Rachel Haney, Dr. Sierra Beck

Case Editors: Dr. Miriam Cordeiro Stone

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References

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