A 38-year-old man who had been treated with warfarin since mitral valve replacement 10 years earlier presented with acute onset of epigastralgia and melena. Coagulation tests were abnormal with a prolonged prothrombin time of >60 seconds and a prolonged activated partial thromboplastin time of >120 seconds. Abdominal sonographic examination revealed duodenal intramural hematoma that was confirmed on CT. Warfarin therapy was stopped and the patient was treated conservatively with vitamin K and fresh frozen plasma. Recovery was uneventful, and the patient was re-warfarinized 2 weeks later. Duodenal hematoma can be readily diagnosed with bedside sonography.

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Purpose Trauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. Accidents and their adverse events were the sixth leading cause of death and accounted for over 7,000 casualties in 2009. However, a lack of accuracy in identifying the severity of a patient’s injury and their prehospital information can result in inappropriate triage. This study evaluated the efficacy of field triage guidelines governing trauma team activation in Taipei and explored the characteristics of undertriaged and overtriaged patients. Methods ​This study retrospectively observed all patients with trauma transported to the emergency department by Taipei City public ambulance from 2016, to 2019. The Cribari matrix method was used to assess undertriage and overtriage. A logistic regression was employed to analyze the effect of risk factors in patients with major trauma. Results In this study, 320 and 1,895 patients with trauma had full and limited trauma team activation, respectively. Among them, 664 patients with trauma were older than 65 years, and most of them were injured in a traffic accident.The analysis revealed that patients with a Glasgow Coma Scale score of less than 13, with systolic blood pressure level of less than 90, and with respiratory rate over 30 breaths per minute were more likely to be appropriately triaged. Conclusion The Taipei prehospital field triage guidelines is acceptable but not an ideal tool for identifying patients with major trauma, with an overtriage rate of 48.12% and an undertriage rate of 12.03%.

A 72-year-old man was brought to our emergency department (ED) because of upper abdominal pain. Initial vitals at the triage station were significant only for high blood pressure. Computed tomography (CT) of the abdomen with contrast enhancement revealed an intimal flap over his descending aorta, the infrarenal part. The flap was found throughout the descending aorta until its bifurcation. Stanford type B dissection was initially suspected. However, a reconstructed CT discovered an interesting feature of the aorta. A high aortic bifurcation at the level of the second lumbar vertebrae, in conjunction with bilateral common iliac arteries, appeared in pair, masquerading the CT image as infrarenal aortic dissection. Actually, that was a variant in human anatomy. A reconstructed sagittal view of the CT scan is mandatory for a patient with abdomen pain to avoid misinterpretation of the radiographic image.