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Tue Apr 29 15:58:04 BST 2008

Joe,

Just had a young child come in who fell on his handle bars of his bike and hit his left anterolateral chest in the thoracoabdominal area lateral and inferior to nipple slightly anterior to the anterior axillary line. The ED saw him and were not going to scan him initially, however, he vomited several times and had a 1/10 abdominal pain on physical examination. On my examination very benign abdomen with no peritoneal signs. Had a CT scan of the abdomen read a scant fluid in the left retroperitoneum and right lower quadrant with no solid organ injury. Any free fluid in the abdomen worries me despite having to search for it on the scans for what the radiologist was reading. So, admitted the child for serial exams, watch UOP, follow up labs. Had several more episodes of vomiting over 6 hours in the PICU despite no change in abdominal exam which was now benign. So, rescanned CT abdomen and pelvis with IV contrast again but this time added PO contrast as we routinely do not on our trauma scans. Patient now showed the midline pancreatic transection with "a lot more fluid" around the abdomen and in the retroperitoneum. Taken to the OR for a distal pancreatic resection as pancreas was cut in half. Review of the first CT and can make out the pancreatic injury but it was not obvious but of course we can Monday morning quarterback this and will PI / PR this in our trauma PI process. This was the case that initial CT scan my not stand out and that close clinical follow-up by admitting and repeat scanning can truly help as it did here. 

Child was extubated immediately post-op and today is doing very well.

MRM

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-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of joe.nemeth at mcgill.ca
Sent: Tuesday, April 29, 2008 6:36 AM
To: trauma-list at trauma.org
Subject: pancreatic injury...

Question:

Although it is well known that traumatic pancreatic injury is poorly seen on CT...especially early on, I want to know how many of you have seen significant pancreatic injury which is occult, i.e. benign abdomen on exam...

Timing of exam make a difference?...

Will let you know why I am asking later...

thanks,

Joe

Joe Nemeth MD
Dept. of Emergency Medicine
McGill University
Montreal
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pancreatic injury...