CASE
A 22-year-old man was brought to the ED complaining of abdominal pain after a rollover motor vehicle accident. He was the front seat passenger and was wearing a seat belt. Although he was trapped in the vehicle and it caught on fire, he did not suffer any cutaneous burns.
History The patient's past medical history was significant for attention-deficit hyperactivity disorder. He admitted to using tobacco and alcohol socially, but denied illicit drug use. He denied any medication use or drug allergies. A review of systems was positive for complaints of abdominal pain and anxiety.
Physical examination The patient's vital signs were: BP, 112/51 mm Hg; heart rate, 110 beats/minute; respirations, 23; SpO2, 95% on room air; and temperature, 37.4° C (99.3° F). On ED arrival, he was awake, alert, and oriented but appeared anxious and agitated. His pupils were equal, round, and reactive to light. His head was normocephalic with a 2-cm laceration on the left ear. The patient's neck was without cervical spine tenderness. On lungs auscultation, he had equal bilateral breath sounds. His heart rate and rhythm were normal and all pulses were palpable equally. His abdomen was soft and diffusely tender to palpation, with an ecchymotic area consistent with the car's restraining device (seat belt sign). A Focused Abdominal Sonography for Trauma (FAST) examination was negative. The musculoskeletal examination revealed full range of motion throughout without obvious swelling or deformity.
Diagnostic tests A complete blood cell count was abnormal with leukocytosis with a white blood cell count of 18,400/mcL. His coagulation factors were within normal limits. An arterial blood gas analysis showed elevated PaO2 of 122 mm Hg (normal range, 35 to 45 mm Hg) and low PaCO2 of 29 mm Hg (normal range, 80 to 100 mm Hg) with a normal base deficit. A metabolic panel revealed various mild electrolyte abnormalities, elevated glucose of 145 mg/dL, and elevated ALT and AST at 41 and 52, respectively.
A chest CT showed opacities in the anterior right upper and middle lobes concerning for pulmonary contusion or aspiration. The patient also had a small right pneumothorax as well as a right scapular fracture and a right fifth rib fracture. CT of the abdomen revealed an acute, traumatic, right-sided lumbar hernia with colon and fat herniation. Perihepatic and perisplenic fluid were seen without any evidence of hepatic or splenic laceration (Figure 1). CT of the pelvis showed irregularity of the bladder associated with low-density fluid surrounding the bladder dome, concerning for bladder rupture. A cystogram confirmed intraperitoneal bladder rupture along the right posterior wall of the bladder. A right ankle radiograph revealed a comminuted fracture of the distal fibular diaphysis and a fracture through the posterior malleolus with slight comminution of the posterior tibial plafond articular margin. This was further evaluated with right lower extremity CT.
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