Wet Reads: The Presentation

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altIt’s trauma season again. EMS brings you (with three minutes warning) a young male with a gunshot wound to the right flank.

The Presentation:
It’s trauma season again. EMS brings you (with three minutes warning) a young male with a gunshot wound to the right flank. On initial assessment, he has no shock or respiratory distress. He complains of pain in the region of the GSW, as well as pain in his R leg. Focused trauma exam shows bilateral breath sounds with good air movement, normal heart tones, a non-tender abdomen and a neurovascular exam that is grossly intact. Initial vitals are P 122, BP 150/95, RR 24, sat 97% RA. He has no allergies medical problems or meds.
Stat trauma films, i.e.a CXR and flat abdominal film, are ordered looking for the gross location of the bullet. As the tubes & lines get secured, you complete a more complete head-to-toe exam. The patient has no other obvious injuries or GSW. Rectal tone is normal. He does continue to complain of R leg pain and numbness. The right leg has some vague general weakness throughout. Recheck of pulses shows 2+ flow in the R leg. There is no sacral anesthesia. The left leg is unaffected. The patient’s heart rate is down, there is no evolving shock and the blood pressure remains good.
Portable X-ray of the abdomen is shown. The general surgeon has responded by phone, and requests a CT scan of the chest and abdomen to further define any injuries. You do not have a neurosurgeon available. A transfer to the trauma center is in the cards.
What do the plain X-rays show? How about the CT slice? What additional imaging may be helpful while patient is getting an abdominal CT scan?
See the next page for the diagnosis. 
{mospagebreak title=Diagnosis}  
Diagnosis: GSW to spinal column, L3 fracture and Cauda Equina Injury 
This is simply a neat CT scan, and shows how helpful CT imaging can be in defining trauma-related injury. Basically, the plain abdominal film shows a bullet near the spinal column on the same side as the injury. There is no crossing of the midline. There is some fragmentation of the bullet, supporting impact with the spine (L3 also looks abnormal on the plain X-ray). Based on the initial X-ray and clinical assessment, one adds a focused CT scan of L2-L4 region to the repertoire.
The two issues in this case were (1) whether the abdominal cavity had been violated—which might have required exploration by the general surgeon—and (2) whether the spinal canal had been injured or violated, with associated neurologic injury. The abdominal CT did not show any major injury, although there was a significant retro-peritoneal hematoma on the ipsilateral side—consistent with bullet impact on the spinal column and local blast effect. The dedicated spinal CT showed that the spinal canal was intact, with a gouging-out of the body of L3 (shown).


The neurologic symptoms were harder to sort out. We had initially considered a Brown-Sequard type injury to the cord itself—but the injury was at a level below the cord proper. This injury to L3 alone should have only affected the local nerve roots, whereas clinically more nerve roots were affected. Without CT evidence of a fracture or hematoma to cause a traumatic cauda-equina syndrome, we concluded that the problem was most likely a concussion/blast injury to the cauda equina, thereby affecting multiple nerve roots at and below the injury site.



Off to the trauma center. And by the way—no Solumedrol (its penetrating trauma, and besides I’m thinking of giving up on the use of steriods for spinal trauma).

Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course.



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