A 17-year-old woman with no significant past medical or surgical history presented to the emergency department (ED) as a level 2 trauma activation. The patient was a restrained backseat driver's side passenger in a car traveling approximately 45 mph when a delivery truck ran a red light hitting the driver's side. The front seat air bags did deploy. She denied loss of consciousness and was ambulatory at the scene. Emergency medical service (EMS) reported approximately 6 in of intrusion into the driver's side door. Her only complaint on arrival was generalized body aches and abdominal pain. Her last menstrual period was 2 weeks prior to arrival.
Vitals on arrival to the ED are as follows: 97.2 F, blood pressure of 108/62 mm Hg, heart rate of 90 beats/min, respiratory rate of 19 breaths/min, and 100% pulse oximetry on room air. Her physical examination was notable for a horizontal abrasion across the abdomen below the level of the umbilicus consistent with a positive seatbelt sign. Multiple other abrasions were noted at the anterior left knee, anterior left shin, and left shoulder. Her remaining physical examination was unremarkable. A focused assessment with sonography for trauma (FAST) was negative. A subsequent computed tomography (CT) abdomen/pelvis with intravenous contrast only per trauma protocol (performed approximately 2 h from the time of the crash) demonstrated a contusion to the lower anterior abdominal wall with no other findings (Figure 1). Her laboratory evaluation was unremarkable, including lactic acid. Given the large contusion to the lower anterior abdominal wall and risk of delayed intra-abdominal injury, even with normal vitals and negative imaging, she was admitted to the trauma service for observation.
Approximately 12 h later she developed worsening abdominal pain, and by 14 h, she had abdominal distention with the absence of flatus/bowel movements. Repeat vitals at 14 h are as follows: 99.2 F, blood pressure of 102/56 mm Hg, heart rate of 96 beats/min, respiratory rate of 21 breaths/min, and 100% pulse oximetry on room air. A repeat abdominal examination was notable for percussive tenderness to the bilateral lower quadrants. A repeat CT abdomen/pelvis with intravenous and oral contrast was performed showing new free fluid favoring extravasation of contrast and concern for perforation. There are a few punctate droplets of air seen within the peritoneal cavity (Figure 2). There is also some enhancement of the peritoneal wall suggesting peritonitis. The patient was taken to the operating room (OR), where she underwent an exploratory laparotomy, small bowel resection for a full-thickness perforation in the ileum, lysis of adhesions, and placement of JP drain x2. Her remaining hospital stay was uncomplicated, and she continued to improve clinically and was discharged on day 7.