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?
Solid organ injures are visualized well without oral contrast. The addition of oral contrast should increase the identification of bowel and mesenteric injuries. However, these are not common injuries (<1%, (1)), and there are findings on non-oral contrast CT that can also identify these injuries. In a recent survey of almost 200 emergency departments, 47% of departments did NOT use oral contrast for imaging blunt trauma. There are several studies looking at the performance of CT with and without oral contrast, and the final conclusion was that CT without oral contrast has a similar diagnostic accuracy to CT with oral contrast in detecting bowel and mesenteric injuries that require surgical repair. (1, 3, 4). We no longer use oral contrast for abdominal imaging in our trauma patients.
2. What do you order now, and what are the possible causes for this patient’s symptom?
This patient clearly is ill, and needs the ‘six things’ if he doesn’t already have them:
IV (two large bore), oxygen (I would place him on 100% NRB oxygen myself, as I’m right there, instead of ordering it), he is already on a monitor, undressed, and already has vital signs. Trauma labs have already been sent.
Because this patient appears ill, with evolving abdominal/chest findings, I would want to review the previous CXR and obtain another one stat now. I would also do a quick FAST exam to look for free fluid. You can also detect pneumothorax with ultrasound. Surgery needs to be involved in the care of this patient, so I would place a call to them.
The causes for this patient’s deterioration include development of pneumothorax, evolving pulmonary contusion, or gastric, spleenic, or other intrabdominal organ injury causing splinting and pulmonary collapse at the left lower lung area. The patient could also have a pulmonary effusion (?hemorrhagic post traumatic), or diaphragmatic injury.
Repeat CXR showed a new, elevated hemidiaphragm on the left similar to the image seen at this site (but my patients did not have an effusion): http://www.google.com/imgres?imgurl=http://www.trauma.org/images/image_library/chest0023a.jpg&imgrefurl=http://www.trauma.org/index.php/main/image/66/C14&h=600&w=800&sz=43&hl=en&start=23&tbnid=WErmNR51fpLfmM:&tbnh=107&tbnw=143&prev=/images%3Fq%3Ddiaphragmatic%2Brupture%26start%3D20%26as_st%3Dy%26ndsp%3D20%26hl%3Den%26sa%3DN
Now you may have your likely diagnosis. With the new elevated hemidiaphragm, he likely has a ruptured diaphragm. In any situation where the patient needs clear and urgent operative care (acute abdomen, positive fast, etc.) I like to call the senior surgical resident at our institution. Non-teaching institutions likely don’t have these challenges, but these are not the types of cases that can wait for the medical student complete evaluation, the surgical intern complete evaluation, then finally several hours later the senior resident and attending involvement. I still call the first year resident, but I also call the person who can get the patient to the OR the fastest.
3. How often will you see delayed presentations of this type of injury?
Rupture of the diaphragm is most commonly associated with road traffic accidents. (5). It is more common in males (male:female ration = 4:1), and more commonly left sided (68%) due to the protection of the liver on the right (6). More than 89% of patients with this type of injury also have an intrabdominal injury (6). It’s not uncommon to miss them on the initial CXR. In one review, only 23% were initially picked up on the initial CXR (7).
It’s not very common, and only occurs in .8-5.8% of patients (8). For a great free review chapter from Imaging an Intervention in Abdominal Trauma by R. F. Dondelinger, (Chapter written by A. Nchimi, D. Szapiro, and R.F. Dondelinger) see this link:
It’s a preview of the book that you can review online.
Outcome: I contacted the senior surgical resident who was in our resuscitation area seeing another patient. He looked at both CXR’s, quickly evaluated the patient, and the patient left for the OR in less than 20 minutes. He survived, but did have a significant tear in the diaphragm, and a spleenic injury.
Here’s one last point: I always ‘eyeball’ turnovers with the leaving team. Finding out about changes in status and personally looking at all the patients has saved several patients in my career (and several lawsuits too). Some people like to do ‘board’ sign-out rounds where the names and status of the work-up are reviewed (without walking around to personally see the patients). You’ll see the actors on the TV show ‘ER’ do this. I would discourage this as there is nothing like the ‘view from the door’ in addition to verbal updates. Emergency medicine is a very dynamic specialty, and conditions can change quickly. That’s one of the things I love about it!
1. Stuhlfaut JW, Soto JA, et al. Blunt abdominal trauma: performance of CT without oral contrast material. Radiology, 2004 Dec;233(3):689-94. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/15516605”
2. Thomas J, Rideau AM,Paulson EK, Bisset GS 3rd. Emergency department imaging: current practice. J AM Coll Radiol. 2008 Jul;5(7):811-816. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/18585658?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum“
3. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004 Feb;56(1):314-22. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/14960973?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed”
4. Stafford RE, McGonigal MD, Weigelt JA< Johnson TJ. Oral contrast solution and computed tomography for blunt abdominal trauma; a randomized study. Arach Surg 1999 Jun;134(6): 622-6. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/10367871?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=5&log$=relatedarticles&logdbfrom=pubmed“
5. Goh BKP, Wong ASY, et al. Delayed presentatin fo a patient with a ruptured diaphragm complicated by castric incarceration and perforation after apparently minor blunt trauma. CJEM vol 6. 277. Entire article available for free at:
6. Shah R, Sabanathan S, Mearns AJ, CHoudhury AK. Ann THorac Surg 1995:60:1444=1449. Accessed at:
7. Hanna WC, Ferri LE, Fata P, et al. THe current status of Traumatic Diaphragmatic injury: Lessons learned form 105 patients over 13 years. Ann THorac Surg 2008;85:1044-48. Accessed at:
8. Nchimi A, Szapiro D, R. F. Dondelinger. Injuries of the Diaphragm, in Imaging an Intervention in Abdominal Trauma by R. F. Dondelinger, Pages 206-236. Preview accessed at: “http://books.google.com/books?id=1zEwsSiL49kC&pg=PT176&lpg=PT176&dq=hawaii+radiograph+ruptured+diaphragm&source=web&ots=itR819Gl7y&sig=KfJU1vWxiYYw6VmSpEcpMqqOlxs&hl=en&sa=X&oi=book_result&resnum=9&ct=result#PPT202,M1“