The paramedics call-in a trauma alert on a 45 year old who ran his 4-wheeler into a tree. He was wearing a helmet, and his only obvious injury is an open fractured distal tib-fib on the right. They splint his fracture, give him morphine 8mg IV per protocol, and apply diesel fuel to the rest of the situation. The trauma team awaits (minus the surgeon, who is in a case).On arrival, the patient is obviously very intoxicated (+1 point for wearing a helmet, -1 point for EtOH use on the 4-wheeler). He knows his name, thinks he is at the hospital, and gives the year as “2000”. Close but no cigar. Vitals are P 110, BP 150/95, RR 28, sat 96% RA. He has bruising on the anterior chest and abdominal walls, but no other major truncal or head/neck findings. His abdomen is soft and slightly tender only to palpation. The neuro exam is non-focal. Portable X-rays and lab are done, and you rapidly irrigate the open fracture followed by a little reduction, a clean dressing and a splint.
The patient is in line for the full Monty CT scanning – head, c-spine, chest, abdomen and pelvis. He remains clinically stable and his head and C-spine CT scans look good. As the labs start to come back, you realize that his alcohol level is only minimally elevated, so he may have more head injury than is apparent. You start the transfer process (no neurosurgery today).
You do a quick wet read of the abdominal CT scan to rule-out any injuries that would require the services of your general surgeon pre-departure. What does it show? Answer on next page.
This case shows nicely how mechanism of injury correlates with actual injury. Even without abdominal wall bruising, this fellow had enough mechanism of injury to get a blow to the head as well as an open tib-fib. To me, that implies “flying through the air” or some such thing. Sure enough, in-between the head and the fractured extremity lies...the rest of him! So we know to hunt for internal truncal injuries in this setting. In children, the combination of the head injury, abdominal solid organ injury and femur fracture is “Waddell’s triad” (found infrequently, perhaps 2% of the time). However, it is prudent to rule out what might be the adult version of this problem.The CT scan shows a nice example of a mesenteric hematoma (see labeled image). There is no free fluid in the abdomen, but you see blood – as increased density – lying along the folds of the mesentery. This comes from presumed “renting” or twisting of the bowel, or simply direct trauma. This injury can be associated with bowel perforation, and can develop into an abscess (late). My surgeon chose to manage this conservatively, and we called for transport to the trauma center.
I did not spend too much time pondering the decision to combine alcohol intoxication with 4-wheeling out in the woods. Early in my career, I might have called him names. Nowadays, I am both more sympathetic and fatalistic. I looked at the trauma nurse, gave a half-grin, and just shook my head. We might judge a little, but mostly we just do our best.
John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course.