interesting case rounds rebecca burton-macleod r4, emerg med june 28 th, 2007
TRANSCRIPT
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Interesting Case Rounds
Rebecca Burton-MacLeod
R4, Emerg Med
June 28th, 2007
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Case
• 11F transferred from PLC to ACH ED after sustaining a vulvar hematoma
• Pt was skateboarding and fell off, landing on her buttocks
• Immediate pain to perineum• Pt stated that swelling noted to genitals
within 5min; when parents arrived home 1hr later, marked swelling
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History
• Any other questions you wish to ask?
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Case cont’d
• On examination:– Hemodynamically stable
– ++ purplish-discolouration bulging mass to R labia; small laceration at 6 o’clock position on R labia
– L labia appears normal
– Unable to examine vaginal opening or other midline structures due to swelling
– Anus normal
– No other signs of trauma
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Physical exam
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Vulvar hematomas
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Vulvar hematoma
• Blood supply:– Pudendal artery– Posterior rectal artery– Transverse perineal artery– Posterior labial artery
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Causes of injury
• Straddle injuries (75% of cases in peds)
• Sexual abuse
• Kicks
• Self-inflicted wounds
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Vulvar hematoma
• Mgmt ?
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Mgmt
• No further rapid expanse of hematoma
• Pain control
• Ice packs to groin
• Observe for ability to void
• D/W Gyne
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Vulvar hematoma
Kanai M et al. Warning from Nagano: increase of vulvar hematoma and/or lacerated injury caused by snowboarding. J Trauma. 50(20). 2001.
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Mgmt
• Conservative– Small hematomas
– No rapid expanse
– Patient able to void
• Surgical– Large, rapidly
expanding hematomas
– Inability to void due to swelling
– Infective complications
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Mgmt
• Conservative mgmt:– Observation– Ice packs– Ice Sitz baths– Tetanus (if appropriate…)
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Surgical mgmt
• I + D
• Ligation of bleeding arteries
• If suspected retroperitoneal hematoma:– Laparoscopy – Exploratory celiotomy
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Imaging
• U/S ?
• Case report – Blunt straddle injury with L labial swelling and
++ pain– Transperineal U/S performed to more
accurately measure size and extent of vulvar hematoma
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U/S
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CT
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Summary
• Conservative mgmt if small, nonexpanding hematoma
• Involve Gyne if rapidly expanding, unable to urinate
• No role for imaging at this time…
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Questions ?