There are two choices: (1) observe the patient, or (2) ct the patient. The patient has no obvious serious injuries, but simply discharging this patient is a bad idea given the mechanism and his injuries. The patient can be observed in the ED or as an inpatient.
We CT’d the patient’s chest. We were looking for a scapula fx, rib fxs, and pulmonary contusions. These are relatively minor injuries, but very likely given the patient’s physical exam.
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(1) A negative FAST means nothing, esp if it’s done only once.
(2) Pan-scans do not need to be done immediately. If you take a wait-and-see approach, it will reduce your imaging.
(3) Patients may compensate well for bleeding, to the point of normal vital signs.
(4) If the shoulder hurts and it’s not the clavicle or the humerus, it may be the scapula.
(5) Patients with pulmonary contusions are hypoxic. If they’re not hypoxic, the pulmonary contusions are minor.
(6) In a twist, trauma surgery did not want to scan this patient, but I did. In all likelihood, the team was mistakenly comforted by the patient’s well appearance and the history of running to the grocery store.
On the non-con chest CT, the patient has a small scapular fx, two L rib fx, and small pulmonary contusions. More concerningly, the patient has a splenic and a L kidney injury on the lower portions of the scan.
By this time, the patient vomited a couple of times, possibly as a reaction to morphine. The patient went back for a pan-scan with IV contrast, which showed “blushes” in the spleen and L kidney. Notably, there is no contrast at all in the left kidney, which implies an injury to the L renal artery. Most patients with renal pedicle vascular injuries are shocky and dying because of excessive bleeding. If the patient isn’t dying and the kidney is dark, it usually means a renal vascular intimal injury.
CT imaging has led to the near-extinction of two common practices in the past – getting an urine from trauma patients and looking for gross blood, or putting in a foley in patients with torso trauma (“fingers and tubes everywhere”). Because we rarely do this anymore, most GU injuries are discovered on the CT table, not in the examining table, but it’s not a big deal.
This was a no-brainer! An observation was definitely not the answer here. This patient has a significant mechanism of injury (consider pedestrian struck to always be a high suspicion mechanism with diffuse injury patterns) plus a tender body part. Tender body part and negative xray probably warrants additional imaging. So a CT would be reasonably prudent in this case.
Oh, but its a lot of radiation and what’s the likelihood of finding something bad with a negative xray, negative E-FAST, and completely normal vitals? Well, check out the NEXUS CT Chest study: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001883 or some really cool guy’s review of that study: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging
Bottom line — whether you’re using your good judgement or a validated clinical decision rule like the NEXUS CT Chest rule, this patient warrants advanced imaging as the current diagnostic workup (physical, CXR, EFAST) are insufficient to rule out major or minor thoracic injury.
The bigger question is to keep going through the abdomen and pelvis with a negative PXR and EFAST, along with a completely non-tender abdomen. I would argue that skipping the CT Abdomen/Pelvis is potentially probably appropriate in the original scenario (based on the REACT-2 trial) but it seems as though in this case we got foxed and there was other stuff to find.
Any thoughts?