of pelvis or multiple long bones, hemopneumothorax, tension pneumotho-
rax, cardiac tamponade, and aortic dissection or rupture. The third peak
period, classified as delayed death, occurs days to weeks following the ini-
tial injury. Death in these patients is usually a result of multisystem organ
failure and sepsis.
128.The answer is b.(Rosen, pp 415-435.)The image reveals fluidin the
space between the right kidney and liver, known as Morison pouch.Free
fluid is seen as an anechoic area (black in color). The FAST examination is
replacing the DPL in cases of abdominal trauma. It is inexpensive, nonin-
vasive, and confirms the presence of hemoperitoneum in minutes. The
minimum amount of intraperitoneal fluid needed for detection by ultra-
sound is approximately 70 cc. Patients who remain unstable despite vol-
ume resuscitation and have intraperitoneal fluid demonstrated by the FAST
examination need to be taken to the OR for a laparotomyto identify and
treat the source of bleeding.
(a)CT scanning is a very useful diagnostic modality in blunt abdominal
trauma allowing for localization of injuries within the abdomen. If the patient’s
vital signs improved after volume resuscitation, or were stable upon presenta-
tion, the patient would undergo an abdominal CT scan. (c)If the FAST exam-
ination was negative and the patient remained hypotensive despite volume
resuscitation, then a DPL should be performed, which may increase the sensi-
tivity of finding an abdominal source of bleeding. (d)With unstable vital signs
and a positive FAST examination, the patient requires a laparotomy. Ideally, he
will receive another liter of crystalloid fluid or blood on the way to the OR.
(e)Serialabdominal examinations may be appropriate in certain cases of
abdominal trauma with stable vital signs and no obvious internal injuries.
129.The answer is c.(Rosen, pp 329-342.) Spearing—hitting another
player with the crown of the helmet—generates an axial loading force that
is transmitted through the occipital condyles to the superior articular sur-
faces of the lateral masses of the first cervical vertebra (C1). This fracture is
commonly referred to as a Jefferson fracture.It is considered an unstable
fracture and is associated with C2 fractures 40% of the time. On plain radi-
ograph, it is best seen on the open-mouth odontoid view as the lateral masses
are shifted laterally. It is associated with diving accidents and in this scenario,
“spearing” in a football game, which places an increased axial load to the
cervical spine. Proper cervical spine precautions should remain in place
throughout his management in the ED.
150 Emergency Medicine