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Emergency Medicine Atlas > Part 1. Regional Anatomy > Chapter 7. Chest and Abdomen > Chest and Abdominal Trauma >

 

 

Traumatic Asphyxia

Associated Clinical Features

Traumatic asphyxia is due to a sudden increase in intrathoracic pressure against a closed glottis. The elevated pressure is transmitted to the veins, venules, and capillaries of the head, neck, extremities, and upper torso, resulting in capillary rupture. Survivors demonstrate plethora, ecchymoses, petechiae (Figs. 7.1 and 7.2), and subconjunctival hemorrhages. Severe cases may produce CNS injury with seizures, posturing, and paraplegia.

Figure 7.1

 

Traumatic Asphyxia This 45-year-old male was pinned when the truck he was working under fell on his chest. He was unable to breathe for 3 to 4 min until his coworkers rescued him. The violaceous coloration of the shoulders, face, and upper chest is apparent. (Courtesy of Stephen Corbett, MD.)

 

Figure 7.2

 

Traumatic Asphyxia A closer view showing the petechial nature of this rash. The patient was observed in the hospital overnight and recovered completely. (Courtesy of Stephen Corbett, MD.)

Differential Diagnosis

Sudden traumatic compression of the superior vena cava produces obstruction similar to that seen in the superior vena cava syndrome. Both demonstrate a violaceous discoloration of the face and neck. History will confirm the diagnosis.

Emergency Department Treatment and Disposition

Treatment is supportive, with attention to other concurrent injuries. Long-term morbidity is related to the associated injuries.

Clinical Pearls

1. Facial petechiae are known as Tardieu's spots.

2. Be alert for associated rib and vertebral fractures.

 

Tension Pneumothorax with Needle Thoracentesis

Associated Clinical Features

A tension pneumothorax results when air is able to enter but not exit the pleural space. Air in the pleural space accumulates and compresses the ipsilateral lung and vena cava, with a rapid decrease in cardiac output. The contralateral lung may suffer ventilation/perfusion (/) mismatch. Subcutaneous air, tracheal deviation, jugulovenous distention (JVD), and diminished or hyperresonant ipsilateral breath sounds can be clues. Subcutaneous emphysema may be visible on the neck and chest and is easily diagnosed by palpation. The released air from a tension pneumothorax can be heard escaping from a needle thoracostomy.

Differential Diagnosis

Cardiac tamponade, congestive heart failure with pulmonary edema, esophageal intubation, and anaphylaxis should be considered.

Emergency Department Treatment and Disposition

Treatment requires rapid recognition of the tension pneumothorax, frequently without benefit of chest radiographs. A large-bore needle (at least 14 gauge) should be placed over the superior rib surface of the second interspace in the midclavicular line (Fig. 7.3). A rush of air with improvement of vital signs confirms the diagnosis. A syringe loaded with sterile saline allows visualization of air return but is not mandatory. If there is no immediate improvement, do not hesitate to place a second needle in the next interspace. A chest tube should be placed as soon as possible. Ventilation with appropriate inspiratory/expiratory ratio would prevent further occurrences.

Figure 7.3

 

Tension Pneumothorax A 35-year-old male with severe asthma suffered respiratory arrest during transport by ambulance. He was intubated on arrival but soon became hard to ventilate and developed subcutaneous emphysema followed by hypotension. Needle thoracostomy produced a rush of air and bubbling from the needle with stabilization of vital signs. (Courtesy of Stephen Corbett, MD.)

Clinical Pearls

1. Do not overventilate patients with obstructive pulmonary disease. "Stacking" breaths trap air in the lungs and predispose to bleb rupture and pneumothorax. The pathophysiology of this disease requires a prolonged expiratory phase.

2. The diagnosis of a tension pneumothorax is made clinically and should be treated immediately with a needle thoracostomy and ultimately a tube thoracostomy.

 

Cardiac Tamponade with Pericardiocentesis

Associated Clinical Features

Beck's triad of acute cardiac tamponade includes jugulovenous distention (JVD) from an elevated central venous pressure (CVP), hypotension, and muffled heart sounds. In trauma, only one-third of patients with cardiac tamponade demonstrate this classic triad, although 90% have at least one of the signs. The simultaneous appearance of all three physical signs is a late manifestation of tamponade and usually seen just prior to cardiac arrest. Other symptoms include shortness of breath, orthopnea, dyspnea on exertion, syncope, and symptoms of inadequate perfusion.

Differential Diagnosis

Patients with a chronic pericardial effusion have an elevated CVP and a small, quiet heart but are relatively asymptomatic and without hypotension.

Emergency Department Treatment and Disposition

The clinical diagnosis of tamponade requires suspicion and a careful evaluation of the signs and, when available, imaging techniques. Two-dimensional echocardiography represents the ultimate standard for diagnosis. ED pericardiocentesis (Fig. 7.4) is a diagnostic and resuscitative procedure in patients with suspected cardiac tamponade. Goals of ED pericardiocentesis include identification of pericardial effusion and removal of blood from the pericardial space to relieve the tamponade.

Figure 7.4

 

ED Pericardiocentesis A positive pericardiocentesis in a patient with a sudden onset of shortness of breath and electrical alternans. (Courtesy of Lawrence B. Stack, MD.)

Clinical Pearls

1. An electrical alternans seen on a 12-lead ECG suggests pericardial effusion.

2. Beck's triad for acute cardiac tamponade is a late manifestation and is seen in only 30% of trauma patients.

 

Emergency Department Thoracotomy

Associated Clinical Features

ED thoracotomy is a resuscitative procedure performed in patients with penetrating chest trauma who have lost signs of life in the presence of prehospital or ED personnel. Resuscitative thoracotomy (Fig. 7.5) in the ED has specific goals once the chest is opened: relief of cardiac tamponade, support of cardiac function (internal cardiac compressions, cross-clamping the aorta to improve coronary perfusion, and internal defibrillation), and control of hemorrhage from the heart, pulmonary vessels, thoracic wall, and great vessels.

Figure 7.5

 

ED Thoracotomy An unsuccessful resuscitative ED thoracotomy with pericardiotomy in a patient with penetrating chest trauma who lost signs of life in the field after the paramedics arrived at the scene. (Courtesy of Alan B. Storrow, MD.)

Differential Diagnosis

Few conditions present that require immediate ED thoracotomy. A trauma patient who has lost vital signs prior to arrival of prehospital personnel is deceased and not a candidate for this procedure.

Emergency Department Treatment and Disposition

Patients with penetrating thoracic trauma who lose their vital signs en route to the ED should receive an immediate thoracotomy on arrival by the most experienced provider. Patients with penetrating thoracic trauma whose blood pressure cannot be maintained above 70 mmHg with aggressive fluid and blood management should be considered for ED thoracotomy. Patients with blunt trauma who lose their vital signs en route to the ED should not undergo an ED thoracotomy, since they rarely survive. Surgical support should be notified as soon as possible.

Clinical Pearls

1. Injuries potentially responsive to resuscitative ED thoracotomy include cardiac tamponade, pulmonary parenchymal and tracheobronchial injuries, large-vessel injuries, air embolism, and penetrating heart injuries.

2. Resuscitative ED thoracotomy should be performed immediately once the indications have been met, since the likelihood of survival is greater when this is performed earlier in the resuscitation.

 

Diagnostic Peritoneal Lavage (DPL)

Associated Clinical Features

Diagnostic peritoneal lavage (DPL) was introduced in 1965 as a simple, fast, and reliable technique to identify hemoperitoneum in patients with blunt and penetrating abdominal trauma. It is performed by placing a catheter into the peritoneum, aspirating for gross blood, and introducing 1 L of crystalloid if the initial aspiration is negative (Fig. 7.6). The lavage fluid is then withdrawn and white and red cell blood counts are obtained. Interpretation of the results is based on the type of trauma. A "grossly positive" DPL is evident when 10 mL of blood is obtained on the initial aspiration. The procedure is considered positive in blunt abdominal trauma when >100,000 RBC/mm3 or >500 WBC/mm3 are present in the lavage fluid. In penetrating abdominal trauma, the procedure is considered positive when >10,000 RBC/mm3 are present (up to 100,000 RBC/mm3 is used by some). Lavage fluid containing intestinal contents is evidence of perforating bowel injury.

Figure 7.6

 

Positive DPL DPL fluid obtained from this patient with blunt trauma was microscopically positive. Initial aspiration was negative. (Courtesy of Kevin J. Knoop, MD, MS.)

Indications for DPL in blunt trauma include equivocal examination with significant abdominal trauma, unreliable examination (intoxication, spinal trauma, head injury), unexplained hypotension with suspected abdominal injury, and when serial examinations are not possible (in patients going to the operating room for other injuries).

Indications for DPL in penetrating trauma include patients in whom the need for celiotomy is unclear, tangential wounds in which peritoneal penetration is uncertain, stab wounds in which there are no peritoneal signs or signs of peritoneal penetration, and low chest wounds to identify diaphragmatic injury.

Contraindications to DPL include any condition in which a celiotomy is clearly indicated, since this would delay definitive treatment.

Differential Diagnosis

Injuries that may not be diagnosed with DPL include subcapsular liver or spleen hematomas, injury to a hollow viscus, ruptured diaphragm, and ruptured bladder. Retroperitoneal injuries (pancreatic, duodenal) are not diagnosed with DPL.

Emergency Department Treatment and Disposition

A positive DPL is an indication for celiotomy. Patients with negative DPLs are observed or discharged based on a variety of factors including injury mechanism, comorbid disease states, and concurrent traumatic injuries.

Clinical Pearls

1. Intraperitoneal blood (30 mL) will typically give a DPL result of 100,000 RBC/mm3.

2. Controversy exists over the positive cell count in penetrating abdominal trauma, since the range for a positive result can vary between centers from 1000 to 100,000 RBC/mm3.

3. If transfer is indicated, a sample of DPL fluid should accompany the patient.

 

Seat Belt Injury

Associated Clinical Features

Seat belts have reduced mortality and the severity of trauma due to motor vehicle accidents; however, they occasionally produce injury. Injuries caused by the standard three-point restraint harness (Fig. 7.7) are most commonly rib fractures. Injuries caused by the older lap belts include abdominal injuries such as bowel contusion or perforation and lumbar fractures.

Figure 7.7

 

Seat Belt Injury Ecchymosis from the three-point seat belt is clearly seen. The injuries identified are multiple rib fractures and multiple hematomas of the small bowel wall. (Courtesy of Stephen Corbett, MD.)

Differential Diagnosis

A careful primary and secondary survey identifies most injuries caused by seat belt use. Difficult diagnosis occurs in the case of bowel perforation or diaphragmatic rupture, in which signs and symptoms may not occur until hours or days after the initial injury.

Emergency Department Treatment and Disposition

Patients with a mechanism for significant trauma or with other injuries requiring admission should be admitted for observation or definitive treatment. Patients discharged home from the ED should be given appropriate precautions to monitor for a delayed injury presentation.

Clinical Pearls

1. Maintain a high suspicion for intraabdominal injury when ecchymosis from a seat belt is seen in a trauma victim.

2. When lap belt bruises are present, there is a higher incidence of bowel injury.

 

Grey-Turner's Sign and Cullen's Sign

Associated Clinical Features

Bluish to purplish periumbilical discoloration (Cullen's sign) and left flank discoloration (Grey-Turner's sign) represent retroperitoneal hemorrhage that has dissected through fascial planes to the skin (Fig. 7.8). Retroperitoneal blood may also extravasate into the perineum, causing a scrotal hematoma or inguinal mass. This hemorrhage may represent a hemodynamically significant bleed.

Figure 7.8

 

Grey-Turner's and Cullen's Signs This patient displays both flank and periumbilical ecchymoses characteristic of Grey-Turner's and Cullen's signs. (Courtesy of Michael Ritter, MD.)

Differential Diagnosis

Cullen's sign and Grey-Turner's sign are most frequently associated with hemorrhagic pancreatitis (seen in 1 to 2% of cases), and typically are seen 2 to 3 days after onset of acute pancreatitis. These signs may also be seen in ruptured ectopic pregnancy, severe trauma, leaking or ruptured abdominal aortic aneurysm, coagulopathy, or any other condition associated with bleeding into the retroperitoneum.

Emergency Department Treatment and Disposition

Treatment of patients with Grey-Turner's sign or Cullen's sign depends on the etiology of the hemorrhage. Because the hemorrhage may represent a hemodynamically significant bleed, cardiovascular stabilization after airway stabilization is of the utmost importance. Once the patient has been stabilized, the source of bleeding can be elicited by selected laboratory [complete blood cell count (CBC), amylase, lipase, human chorionic gonadotropin (HCG)] and diagnostic studies [ultrasound, computed tomography (CT)]. Because of the severity of diseases associated with Grey-Turner's and Cullen's signs, these patients are usually admitted to the hospital.

Clinical Pearls

1. Grey-Turner's sign (flank discoloration) and Cullen's sign (periumbilical discoloration) are due to retroperitoneal bleeding that has dissected through fascial planes.

2. These signs are typically seen 2 to 3 days after the acute event.

3. These signs are seen in only 1 to 2% of patients with hemorrhagic pancreatitis.

 

Impaled Foreign Body

Associated Clinical Features

Stab wounds cause injury to tissue in their path. Stab wounds to the chest, in addition to causing pneumo- or hemothorax, may also cause life-threatening injuries to the heart and major blood vessels (Fig. 7.9). One-third of stab wounds to the abdomen (Fig. 7.10) penetrate the peritoneal cavity. Half of those injuries that penetrate the peritoneum require surgical intervention. The path of the stab wound is difficult to determine if the inflicting object has been removed. The size of the external wound frequently underestimates the internal injury. Impaled foreign bodies to the chest or abdomen pose a complex problem. The object inflicting the injury may also be preventing significant blood loss and therefore should be removed by the trauma surgeon in the operating room.

Figure 7.9

 

Impaled Chest Wound This patient was stabbed in the chest with a butcher knife in a family dispute. The knife was stabilized by EMS providers at the scene and removed in the operating room. Injury was isolated to the right atrium. (Courtesy of Kevin J. Knoop, MD, MS.)

 

Figure 7.10

 

Impaled Abdominal Foreign Body Impaled knife to the left abdomen. (Courtesy of Ian Jones, MD.)

Differential Diagnosis

Determining whether the impaled object has violated the peritoneum or if injury to a significant structure has occurred can be determined by local wound exploration or diagnostic peritoneal lavage (DPL), depending on the stability of the patient and location of the wound (see Fig. 7.13).

Emergency Department Treatment and Disposition

Initial stabilization of the patient (intravenous fluid resuscitation, oxygen, monitoring), obtaining appropriate laboratory studies including blood type and cross-matching, and resource mobilization (trauma team) are important steps in the initial management of penetrating chest or abdominal trauma. Prior to surgical evaluation, stabilization of the impaled foreign object should be performed to prevent further injury.

Clinical Pearl

1. Impaled chest or abdominal foreign bodies should be removed only by the trauma surgeon in a controlled setting.

 

Abdominal Evisceration

Associated Clinical Features

Evisceration of abdominal contents (Fig. 7.11) usually occurs after a stab or slash wound to the abdomen (Fig. 7.12). It is an indication for celiotomy (laparotomy). Other indications for celiotomy in penetrating abdominal trauma include peritoneal injury; unexplained shock; evidence of blood in the stomach, bladder, or rectum; and loss of bowel sounds.

Figure 7.11

 

Abdominal Evisceration Self-induced evisceration with bowel perforation and spillage of food particles is clearly seen in this photograph. This patient went directly to the operating room. (Courtesy of Lawrence B. Stack, MD.)

 

Figure 7.12

 

Abdominal Evisceration Evisceration of small bowel after assault and stab wound to the right lower abdomen. (Courtesy of Frank Birinyi, MD.)

Differential Diagnosis

Superficial laceration without peritoneal penetration, laceration with peritoneal penetration but no visceral injury, and laceration with peritoneal penetration and visceral injury may present with a similar mechanism and need to be differentiated. Consideration of the anatomic boundaries of the abdomen (Fig. 7.13) is important in differentiating abdominal injuries from penetrating chest or retroperitoneal injuries.

Figure 7.13

 

Anatomic Boundaries of the Abdomen Anterior abdomen: Anterior costal margins superiorly, laterally by the anterior axillary lines, and inferiorly by the inguinal ligaments.

Low chest: Nipple line (fourth intercostal space) anteriorly and inferior scapular tip (seventh intercostal space) to inferior costal margins.

Flank: (Shaded blue) Anterior axillary line anteriorly, posteriorly by the posterior axillary line, inferiorly by the iliac crest, and superiorly by the inferior scapular tip. The back is bounded laterally by the posterior axillary lines.

Back: Inferior scapular tip to iliac crest and posterior axillary lines.

Emergency Department Treatment and Disposition

Initial stabilization (intravenous fluid resuscitation, oxygen, and monitoring), obtaining appropriate laboratory studies including a blood type and cross-matching, and resource mobilization (notifying surgical team, operating room, and anesthesiology) are important steps in the initial management of penetrating abdominal trauma. In most cases, definitive treatment is celiotomy.

Clinical Pearls

1. Indications for celiotomy after penetrating wounds to the abdomen include evisceration; peritoneal signs; unexplained hypotension; blood in the stomach, bladder, or rectum; and loss of bowel sounds.

2. Selected patients with stab wounds to the abdomen and peritoneal penetration may be conservatively observed for delayed complications.

3. As many as 20% of patients with stab wounds to the abdomen can be discharged from the ED based on a negative wound exploration.

 

Traumatic Abdominal Hernia

Associated Clinical Features

Blunt traumatic abdominal hernia is defined as herniation through disrupted musculature and fascia associated with adequate trauma, without skin penetration, and no evidence of a prior hernial defect at the site of injury (Fig. 7.14). This occurs when a considerable blunt force is distributed over a surface area large enough to prevent skin penetration but small enough to cause a focal defect in the underlying fascia or muscle wall. Most of these injuries are due to seat belt injures in motor vehicle crashes; handlebar injuries are the second most common cause.

Figure 7.14

 

Traumatic Abdominal Wall Hernia This 5-year-old boy suffered a traumatic hernia from a handlebar injury. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Existing hernia, abdominal wall hematoma, and abdominal wall contusion should be considered in evaluating a patient with focal blunt trauma to the abdomen and possible hernia. Abdominal computed tomography (CT) with contrast is the diagnostic procedure of choice in the evaluation of abdominal trauma (Fig. 7.15). Ultrasound may play a limited role in the diagnosis of abdominal wall hernia.

Figure 7.15

 

CT Scan, Abdominal Wall Hernia Abdominal contents are seen extruding through a fascial defect. (Courtesy of Lawrence B. Stack, MD.)

Emergency Department Treatment and Disposition

Identification and treatment of life-threatening associated injuries takes priority over the hernia. The hernial defect should be repaired after the patient has been stabilized.

Clinical Pearls

1. Abdominal hernia due to blunt trauma is a rare injury, most frequently due to seat belt injuries in motor vehicle crashes.

2. CT scan is the diagnostic procedure of choice for abdominal wall hernia.

 

Respiratory Retractions

Associated Clinical Features

Increased respiratory effort may be manifest by increased respiratory rate, increased chest wall excursion, and retractions of the less rigid structures of the thorax. Retractions of the sternum (Fig. 7.16), suprasternal notch (Fig. 7.17), and intercostal retractions reflect increased respiratory effort. This may be due to obstructive disease such as asthma or tracheal obstruction, pneumonia, or restrictive disease. The presence of stridor, wheezing, or rhonchi will help distinguish the cause.

Figure 7.16

 

Sternal Retractions Sternal retractions in a patient with croup. (Courtesy of Stephen Corbett, MD.)

 

Figure 7.17

 

Suprasternal Retractions Suprasternal retractions in an adolescent with severe asthma. (Courtesy of Kevin J. Knoop, MD, MS.)

Differential Diagnosis

Asthma, chronic obstructive pulmonary disease, emphysema, epiglottitis, croup, foreign-body aspiration, esophageal foreign body, bacterial tracheitis, posterior pharyngeal abscess, and anaphylaxis are all conditions that must be considered in a patient with retractions.

Emergency Department Treatment and Disposition

An aggressive search for the cause of the retractions is required to direct therapy. Rapid evaluation of the airway for patency and breathing for oxygenation should be done immediately on presentation. High-flow oxygen by face mask is appropriate for patients in respiratory distress. Preparations for securing an airway should be underway for those patients in severe distress or respiratory failure. Routine measures for the mildly symptomatic patient depend on the cause of the retractions. For asthma or exacerbations of chronic obstructive pulmonary disease (COPD), nebulized 2 agonists and steroid therapy may be appropriate. Patients with croup may require nebulized normal saline and possibly epinephrine or dexamethasone as initial therapy. Foreign-body aspiration requires consultation for confirmation of the suspected diagnosis and removal.

Clinical Pearls

1. Retractions are best observed with the patient at rest with the chest exposed.

2. Retractions from obstructive airway disease can be intercostal and supraclavicular and are usually accompanied by nasal flaring, increased expiratory phase, and increased respiratory rate.

 

Superior Vena Cava Syndrome

Associated Clinical Features

This symptom complex develops from obstruction of venous drainage from the upper body, resulting in increased venous pressure, which leads to dilation of the collateral circulation. Superior vena cava (SVC) syndrome is most commonly caused by malignant mediastinal tumors. Dyspnea; swelling of the face, upper extremities, and trunk; chest pain, cough, or headache may be present. Physical findings include dilation of collateral veins of the trunk and upper extremities, facial edema and erythema (plethora), cyanosis, and tachypnea (Fig. 7.18).

Figure 7.18

 

Superior Vena Cava Syndrome A 27-year-old man with SVC syndrome. Note the prominent collateral veins of the chest and neck. (Courtesy of William K. Mallon, MD.)

Differential Diagnosis

Malignancy, pericarditis, pericardial tamponade, tuberculosis, and congestive heart failure should be considered.

Emergency Department Treatment and Disposition

Radiation therapy is the treatment of choice for most malignant mediastinal tumors causing SVC syndrome. Administration of corticosteroids and diuretics initiated in the ED may provide temporary relief pending definitive therapy.

Clinical Pearls

1. SVC syndrome is most commonly caused by malignant mediastinal tumors.

2. Treatment of most mediastinal tumors causing SVC syndrome is radiation therapy.

3. CT scan of the chest is the diagnostic modality of choice for patients with SVC syndrome.

 

Apical Lung Mass

Associated Clinical Features

Pancoast's tumor involves the apical lung and may affect contiguous structures such as the brachial plexus, sympathetic ganglion, vertebrae, ribs, superior vena cava, and recurrent laryngeal nerve (more common for left-sided tumors). Horner's syndrome, extremity edema, nerve deficits, hoarseness, and superior vena cava syndrome may result. Erosion of tumor through the chest wall can cause compression of venous outflow, with resultant jugulovenous distention (JVD) (Fig. 7.19).

Figure 7.19

 

Apical Lung Mass This 68-year-old male cigarette smoker complained of cough and weight loss. A chest radiograph shows a left apical tumor. There is erosion of the tumor into the chest wall, with an indurated supraclavicular and infraclavicular mass. Moderate JVD is apparent, suggesting venous outflow obstruction. (Courtesy of Stephen Corbett, MD.)

Differential Diagnosis

Virchow's node of abdominal carcinoma, lymphoma, vascular abnormalities, and tuberculosis should be considered.

Emergency Department Treatment and Disposition

Treatment depends on the staging and type of tumor. The superior vena cava syndrome can be treated acutely with radiation and diuretics. Thrombolytic therapy has been used successfully in some cases of acute vena caval thrombosis.

Clinical Pearls

1. Thrombosis may cause acute decompensation with edema, plethora, and airway collapse.

2. Prompt radiation therapy can be lifesaving in cases of vena caval obstruction.

 

Jugulovenous Distention

Associated Clinical Features

Central venous (right atrial) pressure is reflected by distention of the internal or external jugular veins. Normal pressure is less than 3 cm of distention above the sternal angle of Louis. Distention greater than 4 cm should be considered abnormal. Evaluation begins by raising the head of the supine patient 30 to 60 degrees. The highest point of venous pulsation at the end of normal expiration is measured from the sternal angle of Louis. The presence of jugulovenous distention (JVD) (Fig. 7.20) should prompt an immediate search for possible pulmonary or cardiac pathology. The presence of crackles, murmurs, rubs, percussed hyperresonance, or crepitus may help disclose the etiology.

Figure 7.20

 

Jugulovenous Distention An engorged external jugular vein is noted as it crosses the sternocleidomastoid muscle into the posterior triangle of the neck and disappears beneath the clavicle to join the brachiocephalic vein and the superior vena cava. This patient has severe congestive heart failure requiring intubation. (Courtesy of Stephen Corbett, MD.)

Differential Diagnosis

Causes of JVD include right ventricular failure, left ventricular failure, biventricular failure, parenchymal lung disease, pulmonary hypertension, pulmonic stenosis, restrictive pericarditis, superior vena cava syndrome, pulmonary embolus, tricuspid valve outflow obstruction, tension pneumothorax, increased circulating blood volume, and atrial myxoma. Temporary venous engorgement may result from Valsalva maneuver, positive pressure ventilation, and Trendelenburg position.

Emergency Department Treatment and Disposition

Treatment varies depending on the cause. Preload reduction may help in cases of congestive heart disease. Reversal of a traumatic etiology with needle thoracostomy or pericardiocentesis may be required.

Clinical Pearls

1. Right-sided myocardial infarction may produce JVD with clear lung fields.

2. JVD may be absent in the presence of the above-listed causes if hypovolemia is present.

 

Caput Medusae

Associated Clinical Features

Veins of the abdomen normally are scarcely visible within the abdominal wall. Engorged veins, however, are often visible through the normal abdominal wall. Engorged veins forming a knot in the area of the umbilicus are described as a caput medusae (Fig. 7.21). The extent of associated findings depends on the underlying etiology. It is usually secondary to liver cirrhosis, with subsequent portal hypertension and development of circulation circumventing the liver.

Figure 7.21

 

Caput Medusae This elderly female with alcoholic cirrhosis has engorged abdominal veins in the knotted appearance consistent with caput medusae. (Courtesy of Gary Schwartz, MD.)

Differential Diagnosis

Emaciation, inferior vena caval obstruction, superior vena caval obstruction, portal vein obstruction, and superficial abdominal vein thrombosis can cause engorged abdominal veins.

Emergency Department Treatment and Disposition

Treatment is directed at the underlying cause. This finding by itself does not require acute treatment.

Clinical Pearl

1. Caput medusae has the same clinical significance as the more common pattern of venous engorgement.

 

Abdominal Hernias

Associated Clinical Features

A hernia is a tissue protrusion through an abnormal body cavity opening. Most abdominal wall hernias occur at the groin and umbilicus. Incarceration is defined as the inability to reduce the protruding tissue to its normal position. Strangulation occurs when the blood supply of the hernia's contents is obstructed and tissue necrosis ensues. An incisional hernia (Fig. 7.22) may manifest clinically as a mass or palpable defect adjacent to a surgical incision and can be reproduced by having the patient perform Valsalva's maneuver. Obesity and wound infection, which interfere with wound healing, predispose to the formation of incisional hernias. The defect of an indirect inguinal hernia (Figs. 7.23, 7.24) is the internal (abdominal) inguinal ring and may be manifest in either sex by a bulge over the midpoint of the inguinal ligament that increases in size with Valsalva's maneuver. A fingertip placed into the external ring through the inguinal canal may palpate the defect. A direct hernia (Fig. 7.25) may be manifest by a bulge midway adjacent to the pubic tubercle and may be felt by the pad of the finger placed in the inguinal canal. The defect is in the posterior wall of the inguinal canal. Direct inguinal hernias are usually painless and occur in males.

Figure 7.22

 

Incisional Hernia An incisional hernia in an obese female. (Courtesy of Stephen Corbett, MD.)

 

Figure 7.23

 

Indirect Inguinal Hernia A recurrent indirect inguinal hernia in a female patient. (Courtesy of Frank Birinyi, MD.)

 

Figure 7.24

 

Indirect Inguinal Hernia This 35-year-old man has an incarcerated indirect inguinal hernia (A) with small bowel obstruction (B). (Courtesy of Lawrence B. Stack, MD.)

 

Figure 7.25

 

Direct Inguinal Hernia A direct inguinal hernia. Note the bulge adjacent to the left pubic tubercle. (Courtesy of Daniel L. Savitt, MD.)

Nausea and vomiting may be present if incarceration with bowel obstruction occurs. Strangulation can lead to fever, peritonitis, and sepsis.

Differential Diagnosis

Tumor, aneurysm, lymphadenopathy, bowel obstruction, ascites, lipoma, femoral hernia, hydrocele, testicular torsion, and epididymitis may have similar presentations.

Emergency Department Treatment and Disposition

When patients present without clinical evidence of strangulation (fever, leukocytosis, systemic signs of toxicity), reduction should be attempted. In the presence of these signs, prompt surgical consultation is warranted for surgical reduction. Reduction in the ED is facilitated with systemic analgesia (as most patients present with significant pain), placing the patient in the supine position, and applying a cold pack to the hernia. Routine consultation for operative repair is indicated in asymptomatic patients with reducible hernias.

Clinical Pearls

1. Acutely strangulated or incarcerated hernias require immediate surgical evaluation.

2. Direct inguinal hernias are usually painless.

3. Evaluation and treatment of concomitant exacerbating conditions (cough, constipation, vomiting) prevent recurrences.

 

Umbilical Hernias

Associated Clinical Features

The umbilicus is a common site of abdominal hernias. Predisposing conditions in adults most commonly include ascites and prior abdominal surgery. The size of the defect determines the symptomatology and incidence of incarceration, with smaller defects resulting in more pronounced symptoms and an increased incidence of incarceration. Pain is located in the area of the fascial defect. Contents of the hernia may be palpable and tender. Symptoms of obstruction (nausea, vomiting, and abdominal distention) may be present. If the hernia becomes strangulated (Fig. 7.26), erythema of the overlying skin with fever and hypotension may occur.

Figure 7.26

 

Strangulated Umbilical Hernia The skin overlying a strangulated umbilical hernia is erythematous and tender. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

An omphalocele, gastroschisis, or urachal duct cyst may present as an umbilical mass.

Emergency Department Treatment and Disposition

Reduction is attempted in the stable patient without clinical evidence of strangulation. Treatment of any predisposing conditions (i.e., abdominal paracentesis in the patient with tense ascites) may cause spontaneous reduction and avoid progression of the hernia to strangulation. Routine consultation for elective repair is indicated in asymptomatic patients with reducible hernias.

Clinical Pearls

1. Umbilical hernias in children usually resolve without treatment.

2. Umbilical hernias in adults usually become worse and require elective repair.

 

Patent Urachal Duct

Associated Clinical Features

When the vestigial urachal duct is not obliterated during development, drainage can occur from the bladder to the umbilicus (Fig. 7.27). Cysts can often be palpated between the umbilicus and pubis. Besides drainage and pain, infection of the duct or cyst may occur. Rarely, adenocarcinoma may form in these remnants.

Figure 7.27

 

Patent Urachal Duct This 19-year-old man presented to the ED with clear fluid (urine) draining from the umbilicus, suggestive of a patent urachal duct. (Courtesy of Kevin J. Knoop, MD, MS.)

Differential Diagnosis

Omphalocele, prune belly syndrome, exstrophy of the bladder, gastroschisis, and umbilical hernias are other abdominal wall abnormalities in children.

Emergency Department Treatment and Disposition

Acute treatment is usually not required unless an infection is evident. Routine urologic consultation for surgical revision is indicated. A retrograde study with radiopaque dye will outline the patent duct.

Clinical Pearl

1. This finding should prompt a careful search for other urogenital anomalies.

 

Sister Mary Joseph's Node (Nodular Umbilicus)

Associated Clinical Features

A Sister Mary Joseph's node is a metastasis manifesting as periumbilical lymphadenopathy secondary to abdominal carcinoma (Fig. 7.28). Cancers of the colon may cause pain, change in bowel habits, anemia, and obstruction. In general, left-sided cancers cause obstruction, whereas right-sided tumors may have significant metastases before they create signs and symptoms. These metastases typically involve peritoneal and omental spread with distant metastases to the liver. Spread to the umbilicus is colloquially known as the Sister Mary Joseph's node.

Figure 7.28

 

Sister Mary Joseph's Node Sister Mary Joseph's nodule of patient with gastric carcinoma. (Courtesy of Department of Dermatology, Naval Medical Center, Portsmouth, VA.)

Differential Diagnosis

Other umbilical masses to consider include hernias, ascites, and urachal cysts.

Emergency Department Treatment and Disposition

Prompt referral for staging and treatment of the tumor is indicated. Other signs and symptoms (from obstruction, blood loss, malnutrition, and pain) should be addressed and treated.

Clinical Pearls

1. Virchow's node, presenting as a supraclavicular mass, also heralds bowel carcinoma.

2. A Sister Mary Joseph's node is commonly due to gastric carcinoma.

 

Abdominal Distention

Associated Clinical Features

Abdominal distention may be a symptom—often described by the patient as the feeling of being bloated—or a sign, an obvious protuberance of the patient's abdomen that may or may not be out of proportion to the rest of the body. Other findings vary widely, depending on the cause. In obesity, the abdomen is uniformly rounded while an increase in girth and fat concurrently accumulates in other parts of the body. In patients with ascites, there may be shifting dullness, a fluid wave, bulging flanks, or hepatomegaly. In patients with neoplasms, there may be a palpable mass. In gravid patients, fetal heart tones may be present and fetal motion may be felt. In patients with excess gas from bowel obstruction, there may be absent or high-pitched bowel sounds and absence of bowel movements or flatus.

Differential Diagnosis

Numerous conditions present with abdominal distention. Obesity, ascites, pregnancy, neoplasms, aneurysm, tympanites (excess gas), organomegaly, and feces are important etiologies to consider in the differential.

The profile of the fluid-filled abdomen of ascites (Fig. 7.29) is a single curve from the xiphoid process to the pubic symphysis. The umbilicus may be everted, and there may be prominent superficial abdominal veins. Other physical findings suggestive of ascites include shifting dullness and a fluid wave.

Figure 7.29

 

Ascites Ascites in an alcoholic man. Note the everted umbilicus and prominent superficial abdominal veins. (Courtesy of Alan B. Storrow, MD.)

 

The pregnant abdomen profile (Fig. 7.30) shows the outward curve to be more prominent in the lower half of the abdomen. The umbilicus may be everted in the last trimester of pregnancy. Prominent abdominal wall veins may also be seen. The presence of fetal heart tones confirms the diagnosis.

Figure 7.30

 

Gravid Abdomen The abdomen of a woman at 39 weeks' gestation. Note the abdominal wall striae, everted umbilicus, and prominent superficial abdominal wall veins. (Courtesy of Stephen Corbett, MD.)

 

The abdominal profile of a patient with a leaking abdominal aortic aneurysm (Fig. 7.31) shows a mottled abdominal wall reflective of hypoperfusion of this structure. There may be a curve of the midabdomen to either side of the aorta, more often on the left. Palpation of a pulsatile mass supports the diagnosis. Ultrasound or computed tomography (CT) of the abdomen will confirm the diagnosis.

Figure 7.31

 

Abdominal Aortic Aneurysm A. The abdomen of a patient with a leaking abdominal aortic aneurysm. Note the mottled abdominal wall and the prominent curvature of the right side of the abdomen. (Courtesy of Stephen Corbett, MD.) B. Abdominal aortic aneurysm seen on ultrasound in another patient. (Courtesy of Sally Santen, MD.)

 

Excess abdominal air (Fig. 7.32) can be located in the lumen of the stomach or intestines or free in the peritoneum. This abdominal profile is a single curve from the xiphoid process to the pubic symphysis. Nausea, vomiting, decreased bowel sounds, and colicky pain are present in a small bowel obstruction. Large bowel obstruction may be accompanied by feculent vomiting and absent production of flatus.

Figure 7.32

 

Pseudoobstruction An 85-year-old woman was brought from a nursing home with a complaint of abdominal distention and pain for 1 to 2 days. An eventual diagnosis of Ogilvie's syndrome, or pseudoobstruction of the large bowel, was made. This is usually seen in debilitated patients and can be treated with decompression. (Courtesy of Stephen Corbett, MD.)

Emergency Department Treatment and Disposition

Treatment varies widely depending on the cause; thus emergent management is directed at determining the etiology. Life-threatening causes (aneurysm, obstruction, neoplasms) require stabilization and referral for definitive treatment.

Clinical Pearl

1. The "six f's" can categorize conditions causing abdominal distention: fat, flatus, fetus, fluid, feces, fatal growth.

 

Intertrigo

Associated Clinical Features

Intertrigo is a dermatitis occurring on apposed surfaces of skin, such as the creases of the neck, folds of the groin and armpit, or a panniculus (Fig. 7.33). It is characterized by a tender, red plaque with a moist, macerated surface. A candidal infection may result and often becomes secondarily infected with skin flora. Erythema, fissures, burning, itching, exudates, and fever may also accompany intertrigo.

Figure 7.33

 

Intertrigo of the Panniculus Note the exudate, erythema, and fissures of the abdominal wall. This patient also had fever, suggesting secondary infection. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Necrotizing fasciitis of the abdominal wall, cellulitis, and Candida albicans infection should be considered.

Emergency Department Treatment and Disposition

Local care, empiric topical antifungal treatment, and good personal hygiene are recommended. Intravenous antibiotics initiated in the ED directed against skin flora are recommended if there is secondary infection.

Clinical Pearl

1. Consider necrotizing fasciitis of the abdominal wall if the patient appears septic.

 

Abdominal Wall Hematoma

Associated Clinical Features

Mild trauma may produce hematomas of the rectus sheath (Fig. 7.34). This injury results in intense abdominal pain, which can mimic an acute abdomen. The diagnosis is made by physical examination, since the ecchymosis is not always visible. Palpation of the abdominal wall reveals a tender mass that is accentuated by contraction of the rectus. Ultrasound and computed tomography (CT) may confirm the diagnosis.

Figure 7.34

 

Abdominal Wall Hematoma This 50-year-old man with chronic obstructive pulmonary disease developed right-lower-quadrant pain after an episode of coughing. A repeat examination on the second visit showed clearly visible ecchymosis. There was no coagulopathy and amylase was normal. A CT scan revealed a 10- by 8-cm hematoma in the right rectus abdominis sheath. (Courtesy of Stephen Corbett, MD.)

Differential Diagnosis

Multiple causes of abdominal pain must be considered in the differential diagnosis. Careful examination with supplemental imaging studies, if needed, helps with the diagnosis. Two classic signs of retroperitoneal bleeding are Grey-Turner's sign (flank ecchymosis) and Cullen's sign (periumbilical ecchymosis). Hemorrhagic pancreatitis and ruptured ectopic pregnancy, respectively, should be considered.

Emergency Department Treatment and Disposition

Assuming that there is no underlying blood dyscrasia or coagulopathy, hematomas of the rectus sheath usually resolve in 1 to 2 weeks.

Clinical Pearl

1. Fothergill's sign is enhancement of a rectus sheath hematoma when the abdominal wall is tensed. The mass should not cross the midline and should be easier to palpate with abdominal muscle contractions. Intraabdominal masses are more difficult to palpate with such contractions.

 

Abdominal Striae (Striae Atrophicae)

Associated Clinical Features

Abdominal striae are linear, depressed, pink or bluish scar-like lesions (Fig. 7.35) that may later become silver or white. They are caused by weakening of the elastic cutaneous tissues from chronic stretching. They most commonly occur on the abdomen but are also seen on the buttocks, breasts, and thighs. Striae are commonly seen in obesity, pregnancy, Cushing's syndrome, and chronic topical corticosteroid treatment. In Cushing's syndrome, a state of adrenal hypercorticism, the skin becomes fragile and easily breaks from normal stretching.

Figure 7.35

 

Abdominal Striae These striae are seen in a patient with recent weight gain, moon facies, and altered mental status. The patient was diagnosed with Cushing's syndrome. (Courtesy of Geisinger Medical Center, Department of Emergency Medicine, Danville, PA.)

Differential Diagnosis

Obesity, pregnancy, Cushing's syndrome, and chronic topical corticosteroid treatment should be considered.

Emergency Department Treatment and Disposition

This finding seldom presents as a condition requiring acute treatment; thus, attention is directed to determining and treating the underlying cause.

Clinical Pearls

1. Recent striae (pink or blue) with moon facies, hypertension, renal calculi, osteoporosis, and psychiatric disorders are suggestive of Cushing's syndrome.

2. The striae caused by pregnancy typically fade with time, unlike those associated with Cushing's syndrome.

 


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