CT Case 070
A 50-year-old unrestrained male passenger involved in a high speed MVA is brought in by the pre-hospital team to your emergency department after a 60-minute retrieval time.
On arrival he was haemodynamically unstable with persistent SBP of 60mmHg despite blood products.
In emergency he received tranexamic acid (TXA); the Massive Transfusion Protocol (MTP) is commenced and he is transferred immediately to CT and then to theatre.
Describe and interpret the CT images
The CT images demonstrate extensive injury.
Spleen: There is an American Association for the Surgery of Trauma (AAST) grade 5 splenic injury
Kidney: Renal lacerations are small in size and amount to AAST grade 2 injury. There is also a left perinephric haematoma.
When renal injury is present, a delayed phase (excretory phase) scan should be performed to assess for injury to the collecting system. In this case, no contrast extravasation from the collecting system was seen.
This patient also had an acute left adrenal haematoma. It is seen on the non-contrast scan as an almond shaped enlargement of the gland. It can occur on either side and is not uncommonly associated with a renal laceration, as in this case.
Non-contrast CT is generally not performed in trauma. The non-contrast image was part the CT IVP, done to further assess the left renal lacerations. The relatively higher density of the left adrenal gland is consistent with an acute haematoma
Outcome
A laparotomy was performed in theatre, one litre of hemoperitoneum was found (not surprising based on the CT images). His intra-operative management included splenectomy and repair of a transverse colon serosal tear (an injury that is not well demonstrated on CT).
Clinical Pearls
In all patients with splenectomy consideration needs to be made for risk of ongoing infection. Post-splenectomy vaccinations include HiB, meningococcal, pneumococcal, meningitis B.
Traumatic adrenal injury accounts for 0.3-2% of all traumatic injuries. The majority have a favourable outcome and can usually be managed conservatively, without any clinical consequence. Diagnostic incidence has increased in recent years with the increase in imaging following trauma.
Renal injuries account for 10% of abdominal trauma, with the majority being minor. As with splenic injuries, the AAST classification system is used for the grading of renal injuries.
Traumatic renal injuries are usually managed conservatively.
Selective embolisation may be used for cases of active bleeding, and laparotomy indicated for haemodynamically unstable grade V vascular injuries, or if there is a need to explore other injuries.
This patient had a follow up CT IVP at 1 week which showed a resolving perinephric haematoma and no evidence of urinoma or renal collecting system injury.
References
- American Association for the Surgery of Trauma (AAST)
- Fadil Y, Bai W, Dakir M, Debbagh A, Aboutaieb R. Post-traumatic adrenal hematoma: A case report and revue of literature. Urol Case Rep. 2020 Dec 17;35:101534.
- Recommendations for vaccination in people with functional or anatomical asplenia
- Nickson C. Trauma! Abdominal Injuries. LITFL
TOP 100 CT SERIES
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).