spleen, kidneys and abdominal injuries

Monday, December 1, 2014

On any given Sunday, there will be a host of slow motion replays, many from multiple angles, which show in graphic detail a knee or ankle buckling. Orthopedics are the rock stars of NFL injuries, as bones, joints, ligaments and tendons are stretched, torn and broken. Head injuries and concussions are rising in awareness. Forgotten are injuries to the internal organs of abdominal cavity that are diagnosed after the game and away from the glare of the television lights. It can take time for symptoms to develop.

Sometimes you know when you’re hurt and sometimes you don’t. Cleveland wide receiver, Miles Austin, was taken to the hospital after the Browns’ game was over and was found to have an injured kidney. He, the trainers and coaches weren’t certain which play or collision caused the damage. Justin Hunter, the Tennessee Titan wide receiver was hit hard after an interception and returned to play. Only later was he taken from the field to the hospital, where he was diagnosed with a spleen injury.

This is often the case with blunt force trauma to the abdomen. It takes time for bleeding and swelling to reach a point where pain receptors are triggered and symptoms felt. Still, it takes a high index of suspicion to look for and find hidden injuries to abdominal organs.

The history of what trauma befell the victim is always helpful, especially when there is high velocity trauma involved, for example a car wreck or a fall from height. When the patient is in shock, (not the emotional “I can’t function” shock, but the “low blood pressure, fast heart rate, sweating, there isn’t enough blood being pumped to my organs” shock), the search for blood loss often starts in the abdomen and chest. Here is where ultrasound and CT scans have made diagnosing injuries quicker and more efficient.

Football is a violent sport but the hits are more often considered low velocity. Still, a helmet to the abdomen or the ribs can cause significant damage, but the injury is often caused by bruising or swelling and that takes time to develop. The spleen is located in the left upper quadrant of the abdomen just beneath the diaphragm, the muscle that separates the chest from the abdomen, and is protected by the lower ribs. A blow to that area can cause bleeding within the spleen; the associated swelling causes progressive pain. The symptoms may be confusing, since the swollen spleen can irritate the diaphragm and the victim may complain about referred pain to the shoulder (it’s how the pain fibers are wired; blame the design engineer). The spleen can also swell to irritate the stomach and the main complaint might be indigestion. It’s the physical exam that is important in deciding whether the abdomen feels as if there is a potential problem that needs aggressive intervention or whether it’s just an abdominal wall bruise. Clinical judgment is key, since not everybody who is hit in the belly needs a CT scan. On a tangent, the spleen swells below the protection of the ribs in patients with infectious mononucleosis and for that reason, those patients should not be involved in any activity when abdominal trauma is a possibility.

The kidneys are located in the flank, behind all the abdominal organs, in the retroperitoneal space and are almost protected by the ribs. Their location is important because an injured kidney will cause pain but may not cause inflammation of the peritoneum, the sac that contains the major abdominal organs. Peritonitis on physical exam often signals the need to look for problems inside the abdomen. Being hit in the flank or back is a helpful history, but as Mr. Austin found, sometimes, you don’t know when you got hurt. Having back pain is an occupational hazard for football players, but if the kidney has significant injury, blood can be seen in the urine. This is not a necessity, again because of a design flaw. The kidney floats in a pad of fat and is tethered to the body in two place, the first by the artery and vein that supply it with blood and the second by the ureter that drains urine to the bladder. If the kidney is torn away from the ureter, no blood may be seen on urinalysis. That said, the amount of blood in the urine is not necessarily related to the severity of the injury.

Fortunately, technology has become a great ally in the diagnosis and treatment of solid organ injuries. Ultrasound can screen for organ size and abnormal fluid or blood within the abdomen. CT scan is able to diagnose injury and its severity to help plan treatment options. And that treatment is no longer just surgery to remove a damaged organ. Often, the body can heal itself if given time and support, or if there is active bleeding, an interventional radiologist may be able to snake a coil into the damage artery and stop the bleeding.

Unfortunately, there are still many other potential abdominal injuries that like to hide and take even more time to develop, including duodenal hematoma or intestinal perforation or mesenteric tears. Think of an organ and the body can hide damage from it…at least for a while. For that reason, close observation of blunt abdominal trauma victims with repeated physical examination and blood testing is often the wisest course of action. On television with Chicago Hope, Gray’s Anatomy or House, all is resolved in 45 minutes plus commercials, but in the real world, observation and using time wisely to watch over the patient is critically important. Time is the ally in treating many patients and patience can be rewarded as symptoms progress and injuries declare themselves. Just ask Miles Austin and Justin Hunter.

 

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all trauma is not the same

Monday, June 3, 2013

One of the sad truths of medicine is that those who care for trauma victims are excited about their job and the ability to diagnose, treat and potentially heal those who are injured. Of course, it requires trauma victims for those skills to be honed. All traumas are not the same. The approach to blunt or penetrating trauma may require different mindsets, offering intellectual and physical challenges to the specialists involved. The stabbing of the Pittsburgh Steeler, Mike Adams, and the car wreck of retired NBA player, Mookie Blaylock, both would have triggered referral to trauma centers and while the initial approach to resuscitation would be the same, the treatment paths diverge quickly.

The initial resuscitation requires the stabilization of the ABCs. Is the (A) airway intact; are they awake and able to breathe on their own, or is there injury to the face, mouth or neck that would require intubation to put a breathing tube into the trachea. Do the lungs work; is the (B) breathing mechanism intact, so that oxygen can get into the blood stream. Is blood pressure maintained so that blood carrying oxygen can be (C) circulated to the organs of the body.

Injuries are prioritized but normalizing the ABCs are job one. Penetrating wounds to the abdomen caused by a gunshot wound, almost always require an emergent operation to look for damage to internal organs. Stab wounds, like those sustained by Mr. Adams, most frequently damage the liver, small intestine or colon, but as long as the ABCs are stable, there is opportunity to go a little slower and perhaps avoid the OR. While surgeons by nature like to operate, their skills also allow them to decide when it’s appropriate to watchfully wait and re-examine the patient over time.

The decision to wait is perhaps harder than the pone to go forward with an exploratory operation. Watching a patient for a day or two and then having to go to the operating room when the patient develops an infection or starts to bleed can be difficult to explain in retrospect. It is easier to explain a negative exploratory operation was performed and nothing untoward was found. The skill of not operating is as special as the technical skills of cutting into a patient.

Mr. Blaylock presented in a different manner. His injuries, sustained when the car he was driving crossed the center line and hit another vehicle, killing that driver. Reports were that he had a bloodied head and was placed on life support, likely meant that the initial ABCs were unstable, or as likely, his head injury made it difficult for the doctors to evaluate his condition because of his inability to cooperate. In the ideal situation, patients will lie still and do as they are asked, but with a head injury, the patient may be combative and potentially worsen an undiagnosed injury like a broken neck or back. In these situations, the patient is sedated, paralyzed, intubated and placed on a ventilator (taking care of A and B) and allowing the search for injured parts to occur.

Care for the blunt trauma victim is often overseen by the trauma surgeon, who gets to orchestrate when other doctors get involved, but often to their dismay, they do not get to operate. In the stable patient with the ABCs under control, physical exam, supplemented by the ability to peer inside the body with CT scans, has decreased the number of exploratory surgeries that are done. It’s often the orthopedic or neurosurgeons that get to have the fun of operating on body parts, while the trauma surgeon gets the responsibility of looking after the patient as a whole.

More than ever, medicine has combined high touch and high tech to allow surgeons to watch. It’s an approach that would make terrible television. Imagine ER or House with nurses at the bedside, tending to their patients quietly and speaking with family in calm tones. Or the physicians spending time examining the patient and deciding to do nothing, except to wait for 4 hours and do it over again. Rushing to the OR is often the right thing to do, but as trauma, the disease, becomes more understood and technology gets more sophisticated, some victims are spending more time in the ER and ICU than under the knife.

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