trauma

Question 1

A 15-year-old, previously healthy adolescent is brought to the emergency department directly from football practice; he complained of left upper quadrant abdominal pain after being tackled. There was no loss of consciousness; he does not have a headache and has not vomited. He has left shoulder pain that is worse with inspiration. Vital signs include a temperature of 37.2°C, heart rate of 100 beats/min, respiratory rate of 20 breaths/min, blood pressure of 106/65 mm Hg, and room air oxygen saturation on pulse oximetry of 100%. He appears to be in pain but is alert and oriented. His examination findings are significant for left upper quadrant tenderness and slight abdominal distention. His skin is warm and well-perfused; he has good range of motion of all extremities. Two large-bore intravenous lines are placed, and a chest radiograph has normal findings.

Of the following, the BEST abdominal imaging modality to confirm the diagnosis is

A.	computed tomography
B.	magnetic resonance imaging
C.	radiography
D.	ultrasonography

Answer 1

computed tomography

Computed tomography with intravenous contrast is the imaging modality of choice for confirmation of splenic injury in the setting of blunt abdominal trauma.
A hemodynamically unstable patient with blunt abdominal trauma and a focused assessment sonography in trauma examination that shows free intraperitoneal fluid should be considered for direct transfer to the operating room without further imaging.
The primary survey of a child who has sustained trauma should be done in a stepwise fashion, beginning with evaluation and management of the airway, breathing, circulation, and disability (Glascow Coma Scale, pupillary reaction, size and symmetry, blood glucose level).

Question 2

A 14-year-old adolescent boy is being evaluated for persistent symptoms after he sustained a concussion while playing football. He was tackled during a game, hitting his head against the ground with loss of consciousness for an estimated 5 seconds. He immediately complained of headache and vertigo and was removed from play. Head computed tomography performed at that time was normal.

Over the next 3 months, he complained of persistent dull headaches, intermittent vertigo, insomnia, and moodiness. He had trouble focusing and his grades were falling, which he attributed to feeling constantly in a fog.

Before his concussion, the boy had episodic migraine headaches, which occurred infrequently and responded to ibuprofen. There is a family history of depression, and the patient had seen a counselor a few years ago for anxiety symptoms.

At this visit, he is wearing sunglasses. He is alert and answering questions appropriately but appears disengaged. Notable neurologic findings include difficulty with recall of 3 objects after 5 minutes, performance of serial 7s, and tandem gait testing.

Of the following, the element of his history that PREDISPOSES him to this presentation is
A. family history of depression
B. first-time concussion
C. history of anxiety
D. immediate postinjury symptoms

Answer 2

history of anxiety

Postconcussive syndrome is a heterogeneous disorder presenting with persistent physical, psychosocial/emotional, cognitive, and/or sleep symptoms in children after a concussion.
Risk factors for postconcussive syndrome include severe initial symptom burden or delayed onset; loss of consciousness for more than 1 minute at the time of injury; vestibular symptoms; and preinjury history of psychiatric disorders, migraine headache, learning disorder, or repeated concussions.
For postconcussive syndrome, a supportive, multidisciplinary approach to specific symptom management is recommended. Physical and cognitive activity with accommodations as needed performed at a subsymptom threshold, is the current recommendation