a twisting tale…

the case.

It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem ever get any shorter….

At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…

She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).

You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.

Despite further boluses of morphine, she continues to vomit and complain of severe pain….so, you order an abdominal xray.


What’s going on here ?
What are you going to do now ??

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a swollen face…

The Case.

A 36 year old male presents through your sub-acute area with increasing facial pain & swelling. He reports a simple trip and fall 18 hours earlier (no alcohol on board, recalls all events), where his right cheek struck a concrete step. He had no LOC at the time, and has no historical features concerning for intracranial injury.

He is worried today as the swelling ‘just keeps getting worse’.

On examination he has obvious marked right zygomatic/maxillary swelling and ecchymoses. His cranial nerves are ok (particularly extra-occular movements and facial sensation). When you palpate his facial bones, for find something unexpected which leads you to expediting his CT scan….

What has happened here ?
What other injuries may have been sustained ??
What do you do next ???

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iatrogenic acceleration…

The Case.

A 46 year old restrained passenger in a high-speed MVA rolls into the resus bay. She is intubated & sedated [easily ventilated & oxygenated, no evidence of chest trauma], persistently tachycardic @ 160/min with a systolic BP of 90mmHg & has a very postive FAST exam….

She spends less than 15 minutes in your ED (extra IV access, blood transfusion continued, limbs splinted) before heading for a trauma laparotomy. She has a liver laceration (repaired) and capsular haematoma, complete bladder rupture (repaired) and splenic haematoma (managed conservatively). Post-op she goes via radiology for a ‘pan-scan’….

Her post-operative ICU stay is a rocky one, marked by ongoing transfusion, coagulopathy and persistent tachycardia (still around 160 beats per minute). Some 6 hours later with her haemoglobin & INR stable, she remained tachycardic at 150-60 (still sinus) & has developed a temperature of 38.6*C.

What are your thoughts ??

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observing the occult…

The case:

A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!

You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.

This is his supine CXR…

EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….

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a tonne of bricks…

… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.

Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).

These are two of his original xrays.


I thought this case gave me the perfect excuse to share one of my favourite orthopaedic papers that I discovered earlier in the year.

by Yu JS, Cody ME in Emerg Radiol. 2009 Jul;16(4):309-18.