Monday, March 14, 2005

From the Unusual Mechanism Injury Department.....
One of the reasons I like reading The Journal of Trauma is the large number of case reports that are published. Occasionally one will catch my eye, as one last month did:Pneumoperitoneum from Orogenital Insufflation: An Incidental Finding Resulting in Nontherapeutic Celiotomy:
A restrained, 16-year-old female driver presented to our facility after her motor vehicle struck a tree. The patient admitted to falling asleep at the wheel and sustained a transient loss of consciousness. Primary survey found her to be hemodynamically stable, with a Glasgow Coma Scale score of 15. Secondary survey revealed seal belt distribution ecchymosis across her lower abdomen and chest, with mild abdominal pain and tenderness. She underwent an abdominal computed tomographic (CT) scan that showed a small amount of free air located within the lesser sac near the duodenum (Fig. 1). No extravasation of contrast, solid organ injury, or intrathoracic air was noted. She underwent exploration with the presumptive diagnosis of hollow viscus injury. On opening the abdomen, the hepatoduodenal ligament was free of fat and transparent, revealing several small bubbles of air just inside the opening to the lesser sac. This corresponded to the air seen on the CT scan. The air bubbles could be touched by inserting a finger into the foramen of Winslow. An extensive search revealed no intra-abdominal organ injury, bile staining, or remarkable free fluid. The stomach was occluded proximally and the duodenum was insufflated with air (under a pool of saline), with no evidence of leak. A careful sexual history was obtained postoperatively and revealed that the patient had forceful vaginal insufflation during oral sex in the previous 12 hours. No other source of reasonable explanation for the free air could be found. Her postoperative day course was unremarkable and she was discharged home on postoperative day 4.

A discussion of the cause and literature review follow.
So where in the secondary survey do I ask about this?
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