Category Archives: What the heck?

What The Heck! You Make The Diagnosis – The Answer

In my last post, I detailed the following case:

This male patient was brought to the trauma center after a high-speed car crash. He was unresponsive with GCS 3. A bleeding facial laceration was present, as was vomitus in the airway.

Prehospital providers rapidly intubated the patient and inserted an orogastric tube. They rapidly packaged and transported him to the nearest trauma center.  The facial laceration was stapled for bleeding control. The airway was checked with a CO2 color change indicator and was positive. OG was hooked to suction with return of gastric contents.

And here was a lateral cervical spine image:

The main problem is that, if you look closely there are three tubes on the image!

Look carefully at the anterior pharynx and trace the radiopaque markers back. There are two nearly overlapping lines. One extends posteriorly, down into the esophagus. This is the orogastric tube. The distal tip of the other (an endotracheal tube which is only inserted to 12 cm at the teeth) stops where it touches another tube. Another endotracheal tube, the proximal end of which is sitting at the epiglottis!

What the heck??! The medics were interviewed, and the patient was initially intubated successfully. The intubator turned his attention to finding a tube securing device, and when he turned back the tube was gone! So he intubated again but met some resistance. This explained the shallow position of the tube.

The patient was oxygenated well and the “outside” ET tube was removed. Then ring forceps were passed under direct vision and the “inside” tube was removed. A well-positioned ET tube was then reinserted. The patient did well afterwards.

Teaching point: When inserting anything that is partially in and partially out of the body (e.g. guidewires, and now ET tubes) always anchor them with your fingers so they don’t just “disappear.” And if you need more hands, ask for assistance!

Source: personal collection. Not treated at Regions Hospital or even in Minnesota.

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What The Heck! You Make The Diagnosis

Please help figure out what is wrong here. I’m not going to give you much information, though.

This male patient was brought to the trauma center after a high-speed car crash. He was unresponsive with GCS 3. A bleeding facial laceration was present, as was vomitus in the airway.

Prehospital providers rapidly intubated the patient and inserted an orogastric tube. They rapidly packaged and transported him to the nearest trauma center.  The facial laceration was stapled for bleeding control. The airway was checked with a CO2 color change indicator and was positive. OG was hooked to suction with return of gastric contents.

This case occurred in the old days when lateral cervical spine films were initially used to evaluate the c-spine in the trauma bay. Here is the image:

What is your diagnosis? And what does the team need to do?

Please post your answer in the Disqus comment box below, or email me. You might consider Twitter (or is it X now), but it seems somewhat flaky.

Answers in my next post!

Source: personal collection. Not treated at Regions Hospital or even in Minnesota.

 

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What The Heck?! The Answer!

In my last post, I described an elderly pedestrian struck by a car. During the trauma activation, routine chest and pelvic x-rays were obtained. Here was the pelvic image:

Note the odd oval densities across the center of the x-ray. What the heck? What are they?

There are two choices: they are either inside or outside the patient. We had already removed her clothes, so it wasn’t something she was carrying. And if it was inside, we would be able to identify it on the CT scan we had ordered.

But in this case, the x-ray was done early in the secondary survey. Specifically, we did it before we rolled our patient and examined her back.  When we did, here is what we found:

Only it wasn’t in the box. Or on her neck. This one was stuck on her lower back, but not in her clothes. She was suffering from lower back pain, and applied one of these on a daily basis for comfort. We had not rolled the patient prior to the pelvic x-ray.

The pods on these thermal wraps contain a mixture of iron, sodium chloride, sodium thiosulfate, water, charcoal, and sodium polyacrylate that heat up when removed from their package and exposed to oxygen. The iron renders it somewhat radio-opaque, hence their appearance on the x-ray. We did peel it off prior to CT since it would probably create a significant amount of scatter which would degrade the image.

Should we have waited a few more minutes to get the image until we had rolled and examined the back? This is a judgment call. Since our trauma team moves quickly, we are typically ready to head to the scanner in 15 minutes. In order to improve overall CT scan throughput, we have adopted a 5-minute advance notice policy.  To accomplish this, we don’t want to wait until the very end of the resuscitation to get x-rays. That would end up slowing down our process.

You may feel differently about the timing of the images, or you may have a different method of sequencing your CT scanner. Whatever works best for you. But remember, all trauma patients need to be completely undressed and all of their surfaces, nooks, and crannies inspected before they leave the emergency department!

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What The Heck?!

Here’s an interesting case from my image archives.

An elderly female pedestrian was struck by a car. She was hemodynamically stable. During the course of her evaluation as a trauma activation, her clothes were completely removed. (She was kept nice and warm with infrared warmers.)

Early in the secondary survey, chest and pelvic x-rays were obtained. Here is the pelvis image:

What is wrong in this picture?? Leave comments below or tweet your guesses. I’ll publish the answer Friday.

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Nail In The Neck: A Novel Removal Option

Here’s a post from my archive describing a different way to remove the foreign body. This is the technique I used, instead of the standard neck incision. The final incision was just a slight extension of the puncture wound, measuring only 1cm. I was able to grasp the head and pull it out without difficulty. The surprising thing to me was the amount of force I needed to apply to actually pull it out! No bleeding, no problems. The patient was observed for 24 hours and discharged home. He had no complications.

A Cool Way To Remove Embedded Foreign Bodies

Many of us have had the experience of digging into bloody tissue for long periods of time trying to locate the object, even with fluoroscopy. Well, there’s a better way of doing this.

A group in China described a technique using a fancy form of needle localization. They employed a set of instruments normally used for lumbar diskectomy (see photo). This set includes a long 18 Ga needle with a removable hub, several dilators and an outer cannula with a 5.8mm diameter. A pair of 3.8mm grasping forceps is also used.

The foreign body is located using a C-arm fluoroscopy unit and the best approach is planned. The 18 Ga needle is then inserted using fluoro until it touches the object. The hub is removed and dilators are inserted over the needle, one after the other. The outer cannula is then placed over them, and the needle and dilators are then removed. The cannula is manipulated until the foreign body (or a part of it) is located within the cannula. It is then grasped and removed, along with the cannula if needed. If the object is too large to enter the cannula, the cannula is pulled back slightly and the grasper introduced past the end of it to grip and remove the foreign body.

The writers shared the details of 76 patients who had a total of 251 foreign bodies removed over a 6 year period. The depth varied from 2.5 to 8.5cm. Procedure time ranged from 8 to 15 minutes, and fluoro exposure varied from 1 to 4 minutes. Success rate was 100% (all foreign bodies were removed) and there were no complications.

Bottom line: This is a very slick technique that promises to dramatically increase the success rate and decrease complications from removing foreign bodies. The amount of time spent is much less than the brute force technique, as is the amount of soft tissue trauma. Large objects that cannot be grasped with these forceps cannot be removed with this method. Although I am a little concerned that the authors’ results were so perfect, it’s certainly worth a try!

Reference: Percutaneous extraction of deeply-embedded radiopaque foreign bodies using a less-invasive technique under image guidance. J Trauma 72(1):302-305, 2012.

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