A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:
Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.
In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.
Here are some tips for each of the areas:
- Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
- Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
- Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
- Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
- Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
- Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.
Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.
Our patient with the steak knife to the head has been evaluated by CT. The scan shows that the blade enters the right orbit, passing through the medial orbital wall into the ethmoid sinus, turbinates and nasal septum. It then passes into the left orbit along the posterior floor and exits the apex. The optic nerves are not involved, but there may be involvement of the rectus or oblique muscles to the globe. There does not appear to be any involvement of the maxillary sinus.
See why a good exam is important? Gross visual acuity and extra-ocular muscle testing is very important here. Miraculously, all are intact. So now what?
Just yank it out? Absolutely not! Although there is no gross bleeding from the nose or mouth, and none is seen on CT, that doesn’t mean there won’t be! The patient needs to go to the OR, and it may be helpful to have a facial surgeon present just in case. Scopes for evaluating the sinuses and packing materials should be readily available.
Under sedation, the knife can be smoothly withdrawn. An awake patient can tell you how it feels, and whether he is experiencing any bleeding or ocualr changes. If in doubt, the sinuses can be scoped and the globes re-examined.
Note: If troublesome bleeding does occur, this is not an area that is amenable to surgical exploration. The only realistic options available are packing and angioembolization.
So our patient has presented to your ED, on foot, with a steak knife sticking out of his head! You’ve activated your trauma team, so now what do you do?
As always, start with a thorough physical exam. A good exam of the head is imperative, as is a scrupulous neurologic exam. In this case, the blade enters just below the right eye, traveling front to back and staying just about level.
Make sure there are no other injuries. Remember the Dang Factor! Don’t focus on the knife and miss other important injuries. And by all means, don’t take it out in the ED!
Since this patient is stable and neurologically intact, the surgeons will want a better idea of the structures involved under the skin. CT is the best tool for this, although there will be scatter from the metal. Here is a representative image:
So now, think about how you will get this out. Tweet and comment your answers.
Yesterday I presented the case of a young man who shows up at the triage desk in your ED with “something wrong with his head.” I showed an AP skull film, which shows some kind of metallic foreign object. What is it? Where is it? What to do?
First, look at the image carefully. The object is metallic density and appears very thin. But remember, any diagnostic image you view is a 2D representation of a 3D space. You have no idea of the orientation of the object, or exactly where (front to back) it is located. He could be lying on top of it, or it could be stuck in his brain.
At the far left side of the image, the thin metal appears to get even thinner. Dead giveaway! Look at the diagram below.
The knife tang is the thin part of a knife that the handle is fastened to. @andrewjtagg tweeted that he wouldn’t mind seeing a lateral, so here it is.
Yes, it’s a knife. A steak knife to be exact. Somewhere in the middle of the face.
First off, you didn’t need to see these to start doing the right things. Since this is a penetrating injury to the “head, neck or torso” it should trigger any trauma center’s highest level of activation. He is whisked off to the trauma bay and quickly evaluated. He’s obviously awake and alert (he walked in), so what do you need to treat him, and how would you manage it?
Tweet or leave comments. More discussion (and pictures) on Monday.
A young man presents to your emergency department walk-in area. Something is wrong with his head. Here is an AP skull film (when is the last time you got one of those?)
I’ll walk you through my thought processes over the next several days. First, what’s going on? And what should you do now? And next, and so on.
Please tweet and leave comments! My explanation of the initial steps tomorrow.