Clinical Case 091: A Pessimists Guide to Trauma
Had a tough trauma case the other day. Not tough as in: “dying quickly” kind. But tough as in the decision points were not clear, the findings a little equivocal and there were plenty of diagnostic biases and errors available for me to commit.
I have a tendency towards pessimism in my practice – it is not innate, I think it is a learned coping behaviour. And this case demonstrates why I think it is useful!
Here is the case:
30 y.o. guy, young, thin, mostly healthy – but a hard partier – he was accustomed to a bit of booze and had taken more than his share of beatings in the rough nights of Broome!
Hx: was sitting on the ground, minding his own business when a “gang of young ‘uns” approached him. In a classic case of mistaken identity they then proceeded to attack him. He was able to dodge a few blows but then got a really good kick in the left flank – over the posterior costal margin. Our victim then lay on the ground for a few minutes until the coast had cleared, got up and walked to the local night spot where he drank an astonishing amount of spirits and beer. At 07:00 the next morning it was clear that the pain was not getting better – so he made his way to the ED for a “check up”.
I am pretty sure this is not what they mean when the trauma specialist folk talk about “Delayed Resuscitation strategy” – but it is pretty much the norm in my world!
Trauma is all about the mechanism. Getting a clear history of the mechanism and energy involved is key to diagnosis and management. Sometimes this is not possible, so here is a take away point from this post – if in doubt, it is best to assume the mechanism was worse rather than less severe. You will miss less badness!
So on with the story. Our hero has plum normal observations: PR = 85 BP = 115/65 RR = 15, SpO2 = 97% RA, breathing is uncomfortable but not laboured
He is still reasonably hammered – I don’t do routine [alcohol] checks – it is a clinical diagnosis! Knowing the BAL is high will invariably bias your thinking around subsequent management, disability assessment etc… best to assume low GCS due to badness until proven otherwise, esp. in the early assessment where you are still putting the story together.
He is pointing to his left flank and seems to be in a lot of pain for a guy who is not unfamiliar with it. A, B and C all seem good, so ATLS and EMST are no use to us here! He has no other injuries on secondary survey. At this stage his belly feels soft anteriorly, though any pressure on his ribs on the left makes him wince. We need a urinalysis – but none is forthcoming. Hmm odd, all that beer and he isn’t peeing… [this should be a bit of a clue in case you missed it..]
Anyway being me, and being a weekend I decided to pull out the US machine and do an e-FAST (chest, abdo and whatever else needs a look!). What did it show?
Abdo views: no free fluid, good images. My scan of the LUQ [the hard one!] looked… “odd”, “not quite right”. I don’t do enough US to be great at picking subtlety but I know normal and “not quite right” when I see it.
Chest: no pneumothorax, no effusion / blood, and no rib fractures seen. Hmmm… I was kinda expecting some rib fractures – he got a good boot and is really tender in the flank, yet nothing to see… odd.
Cardiac: all normal, no effusion etc.
So here is the next “take home point”: sometimes it is the absence of something that makes you worry. US is all about putting the clinical history and exam into context. Do you see what you expected? If not something is not right. And I did not have a decent explanation of his pain.
Oh yes, and he still was not able to give me a urine sample… so I did what any ED doc does – a litre of crystalloid stat! It was at this stage that the RN wandered in with the VBG that I had taken when I put in the IV.
Hmm… was not expecting that. So this is a trauma patient. But he looked really quite well, normal obs and his FAST scan was “normal”, no free fluid. He has drunk. This lactate is yet another hint, something is not right in the state of Denmark! However, these types of results are easily explained away or ignored if you are in that frame of mind, optimistic that is. Optimism has no place in trauma assessment – you will be dissapointed frequently!
Sometimes when I am a bit lost, unsure as to what I should do next I take the opportunity to go and get a cuppa. I take the chart, boil the kettle and sit in the quiet tea-room. I start writing down my notes – the history, my exam (including the US stuff of course), the obs and other tests… VBG, X-rays, ECGs etc. Then I take a moment to look at what I have written and underline the positives, the significant negatives and the bits that just don’t fit (or I have yet to explain). It is a little meditation I do when faced with uncertainty about a case. I wonder about possible errors or biases that I might have committed in my work-up. I try to come up with a “gut feeling” – what do I think is going on?
So for this case I came up with the following simplified version of events:
1. Trauma – a likely high energy blow to the (L) flank
2. “normal” Obs… now
3. A dodgy looking LUQ view on my FAST US exam
4. An otherwise unexplained lactate rise
5. Still no urine…
When you put it down in simple terms and delete all the noise – it is pretty clear. This man has hypovolemic shock with a compensated BP, or maybe he usually runs a BP of 170/110 [not uncommon in Broome].
We need to find out where it is coming from… just as I started writing out the CT request form the nurse interrupted my “tea break” to show me his urine. It was pretty much frank blood. Ahhhhh… we have our diagnosis!
Often as you write and put all the clues together, that “gut feeling” that you had of things “not being quite right” help solidify our move to further investigation.
Thanks for sharing!
Great case, Casey. It’s a classic Northern Australian hidden diagnosis, with the classic trauma masquerader of tons of booze. I like the pearl “assume the mechanism is worse than you think”. I reckon we frequently underestimate the kinetic energy involved in traumatic injury. All you have to do is watch an episode or two of “Funniest Home Videos” to remind yourself that even seemingly trivial injuries like a single blow to the abdomen or fall from a standing height can result in life threatening injury.