Stupid Pediatric Trauma Surgery Question I need help with...

[MD999]

Me and a buddy are studying some Peds Trauma board type questions and we came across this one.... we dont have the answer to it, was hoping somebody can help us out with this. I think it's based on ATLS principles, but who knows..

Question:
A hemodynamically normal 11 yr old girl is admitted to the PICU for observation after a grade 3 splenic injury was confirmed by CT. Which one of the following items would mandate a prompt laparatomy?

a. WBC of 14500
b. Serum amylase of 220
c. Free intraperitoneal air demonstrated on a followup CT
d. A fall in the hemoglobin from 12 to 8 over 24 hours.
e. Extraperitoneal bladder rupture

I was thinking E, but he said that INTRAperitoneal bladder rupture might be right, but he was arguing C, because of free intraperitoneal air...
I know it's probably not D because it could be dilutional and Hb isnt really a good measure of shock (unless it's really severe, but this girl's stable i guess)...


Any suggestions?

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[skiz knot]

Which one of the following items would mandate a prompt laparatomy?

a. WBC of 14500
b. Serum amylase of 220
c. Free intraperitoneal air demonstrated on a followup CT
d. A fall in the hemoglobin from 12 to 8 over 24 hours.
e. Extraperitoneal bladder rupture

I was thinking E, but he said that INTRAperitoneal bladder rupture might be right, but he was arguing C, because of free intraperitoneal air...
I know it's probably not D because it could be dilutional and Hb isnt really a good measure of shock (unless it's really severe, but this girl's stable i guess)...


Any suggestions?

Uhhhh, I'm an orthopod and I know that free intraperitoneal air gets you a rapid trip to the OR for ex lap. If I'm not mistaken, extraperitoneal bladder injuries are not as serious as intraperitoneal ones.

 

[dynx]

Me and a buddy are studying some Peds Trauma board type questions and we came across this one.... we dont have the answer to it, was hoping somebody can help us out with this. I think it's based on ATLS principles, but who knows..

Question:
A hemodynamically normal 11 yr old girl is admitted to the PICU for observation after a grade 3 splenic injury was confirmed by CT. Which one of the following items would mandate a prompt laparatomy?

a. WBC of 14500
b. Serum amylase of 220
c. Free intraperitoneal air demonstrated on a followup CT
d. A fall in the hemoglobin from 12 to 8 over 24 hours.
e. Extraperitoneal bladder rupture

I was thinking E, but he said that INTRAperitoneal bladder rupture might be right, but he was arguing C, because of free intraperitoneal air...
I know it's probably not D because it could be dilutional and Hb isnt really a good measure of shock (unless it's really severe, but this girl's stable i guess)...


Any suggestions?

wait. are you a resident? seriously dude...free air.

 

[MD999]

Me and a buddy are studying some Peds Trauma board type questions and we came across this one.... we dont have the answer to it, was hoping somebody can help us out with this. I think it's based on ATLS principles, but who knows..

Question:
A hemodynamically normal 11 yr old girl is admitted to the PICU for observation after a grade 3 splenic injury was confirmed by CT. Which one of the following items would mandate a prompt laparatomy?

a. WBC of 14500
b. Serum amylase of 220
c. Free intraperitoneal air demonstrated on a followup CT
d. A fall in the hemoglobin from 12 to 8 over 24 hours.
e. Extraperitoneal bladder rupture

I was thinking E, but he said that INTRAperitoneal bladder rupture might be right, but he was arguing C, because of free intraperitoneal air...
I know it's probably not D because it could be dilutional and Hb isnt really a good measure of shock (unless it's really severe, but this girl's stable i guess)...


Any suggestions?

Yeah I figured both bladder rupture and free air would be a ticket to an urgent lap, but wasn't sure if they were trying to get at the free air showing up on a f/u ct as being an erroneous reading or whatever... So I owe him a beer, he was more right....
thanks

 

[skiz knot]

Yeah I figured both bladder rupture and free air would be a ticket to an urgent lap, but wasn't sure if they were trying to get at the free air showing up on a f/u ct as being an erroneous reading or whatever... So I owe him a beer, he was more right....
thanks

like I said, I guess not clearly enough, and I may be wrong, extraperitoneal bladder injuries aren't as serious as intraperitoneal bladder injuries. I don't think they require an urgent trip to the OR.

Free air on a follow up CT for splenic laceration (on an abdomen that wasn't recently operated on) is almost never an erroneous reading. Free air on a CT is usually pretty easy to spot.

 

[Dr.LeoSpaceman]

Yeah I figured both bladder rupture and free air would be a ticket to an urgent lap, but wasn't sure if they were trying to get at the free air showing up on a f/u ct as being an erroneous reading or whatever... So I owe him a beer, he was more right....
thanks

If you're going by ATLS, extraperitoneal bladder rupture isn't even a "little" right in this context. Extraperitoneal bladder ruptures do not mandate a prompt laparotomy. Intraperitoneal ones do, however.

As the others said, this is a very straightforward question. Don't over think them.

 

[opr8n]

extraperitoneal bladder rupture is treated with a foley
free air is treated with a scalpel

 

[karatekid]

Me and a buddy are studying some Peds Trauma board type questions and we came across this one.... we dont have the answer to it, was hoping somebody can help us out with this. I think it's based on ATLS principles, but who knows..

Question:
A hemodynamically normal 11 yr old girl is admitted to the PICU for observation after a grade 3 splenic injury was confirmed by CT. Which one of the following items would mandate a prompt laparatomy?

a. WBC of 14500
b. Serum amylase of 220
c. Free intraperitoneal air demonstrated on a followup CT
d. A fall in the hemoglobin from 12 to 8 over 24 hours.
e. Extraperitoneal bladder rupture

I was thinking E, but he said that INTRAperitoneal bladder rupture might be right, but he was arguing C, because of free intraperitoneal air...
I know it's probably not D because it could be dilutional and Hb isnt really a good measure of shock (unless it's really severe, but this girl's stable i guess)...


Any suggestions?

A. Non-specific, could be due to trauma related stress, you need a trend if you are going to perform a Xlap. This is done now a days at level 1 trauma centers in US where non-operative management is considered, but most of these patients develop peritonitis as well.
B. Most certainly has a pancreas contusion, No operative interventions unless pancreas is severly injured and you want to do a "small pancreatomy"
C. CT is very sensitive and specific for hollow viscus injury (free air)
D. Non-specific as you already mentioned (Dilution effect and hemorhage), Peds tolorate 8 in Hb
D. You do not operate an extra-peritoneal bladder rupture as somebody has already mentioned

So my answer would defently be C.

Cheers.

 

[SLUser11]

B. Most certainly has a pancreas contusion, No operative interventions unless pancreas is severly injured and you want to do a "small pancreatomy"
C. CT is very sensitive and specific for hollow viscus injury (free air)
Cheers.

Since we're being nitpicky of the OP, I just wanted to point out that CT is not very sensitive at all for hollow viscus injury in trauma.

To the OP, as others have said, the key word for the bladder injury is EXTRAperitoneal. If it were intraperitoneal, a laparotomy would be warranted.

When it comes to these types of questions, it's easy to get caught up in the details and not notice the straightforward correct answer. I think it's important to remember that there are more horses than zebras on certifying exams.

 

[dynx]

B. Most certainly has a pancreas contusion, No operative interventions unless pancreas is severly injured and you want to do a "small pancreatomy"
C. CT is very sensitive and specific for hollow viscus injury (free air)

Cheers.

SLU beat me to the punch on the CT findings. they arent very sensitive at all for sb injury.
also, elevated amylase does not "certainly" mean a pancreatic contusion in the setting of blunt abdominal trauma. In fact, small bowel injury is far more likely the cause in most series.

 

[Randy B]

But free intraperitoneal air is fairly SPECIFIC for perforated viscous, right?

 

[Ronin2258]

But free intraperitoneal air is fairly SPECIFIC for perforated viscous, right?

There isn't much I can think of to put air under the diaphragm as well, given the question. If it shows up on CT, it must be pretty obvious.

This is one of those "read slowly questions" to me. Go over the sentence to make sure that you aren't juxtaposing the intra- and extra- prefixes. I see it as confounding as you as putting free intraperitoneal air in a peds patient. To which, the answer should be the same in both age demographics; bright lights and cold, sharp steel.

I see this is one of those questions that there is a universal approach per ATLS, but throws you off the path by putting it in an unusual patient. Just my opinion, but remember the trauma aspect first, then see how it has to be tailored for a peds patient.

Gads, I can hear my mentor going through my head saying that above paragraph.

 

[filter07]

But free intraperitoneal air is fairly SPECIFIC for perforated viscous, right?

In this specific case, probably. In general, free air could be caused by a few other things:

http://www.learningradiology.com/notes/ginotes/freeairpage.htm