All posts by TheTraumaPro

Nail In The Neck: The Operation

We’ve made sure that our victim of the nail gun to the neck did not need an emergent operation. Vitals are stable, there’s no uncontrolled hemorrhage, and the patient is neurologically intact. We’ve imaged him using CT angiography, and the nail does not appear to have injured any vital structures.

How do we get it out of there? There are two things that need to be considered: where and how. 

Rule of thumb: If a foreign body is located anywhere near vital structures, take it out in the OR, no matter how good you think the imaging is. It may be tempting to just pull it out in the ED, but resist! CT scans look so good, and they are so detailed, but they are not perfect. The ED does not have the equipment, personnel, or lighting necessary if something goes awry.

Rule of thumb: Use all information available to plan the removal procedure. In this case, the head of the nail is to the patient’s right. Therefore, it must be removed from the right side. The CT shows that the nail passes very close to the posterior pharynx, so it will need to be evaluated during the procedure.

This patient was taken to the operating room. During the intubation, direct laryngoscopy was carried out to carefully inspect the entire pharynx and larynx. No evidence of penetration was seen. The entire neck, face, and upper chest were prepped and draped (I like to go overboard in trauma cases; you never know what is going to happen). Fluoroscopy was available.

The classic operation would have been to make an incision along the sternocleidomastoid on the right side. The nail head would be approached directly. Since long, thin objects can be notoriously difficult to locate, fluoro can be very helpful. The exact position with respect to the carotid and jugular can be ascertained. Then the nail head is grasped with a clamp, and the nail gently pulled out along its axis. A nice, long wait for any evidence of bleeding should occur. The area can then be irrigated and the incision closed. Skin antibiotics can be given postop, but only one dose at most.

Having said that, I opted for a different approach based on an old blog post here. Tune in tomorrow to see what I really did.

Nail In The Neck: Part 2

This case involves an accidental nail gun injury to the neck. The patient is hemodynamically stable, neurologically intact, the airway is patent and not threatened, and there is no apparent hematoma. There is a small puncture near the sternocleidomastoid muscle on the right, fairly high on the neck. The nail is not palpable on either side. And the patient only complains of a little discomfort when he swallows.

What to do? First, the patient has passed all the initial decision points that would send us straight to the OR (ABC problems in ATLS jargon). But, per physical exam and initial imaging, the nail must obviously come out. We just have to figure out what we need to know before we take it out, and determine the best way to retrieve it.

Given the patient’s stability, additional imaging will be helpful. Views in different planes, and details of what the nail might have passed through will be invaluable. The recommended study is a CT angio of the neck. This will give good information about nearby structures and the vasculature. And software reconstructions will provide good 2D/3D information for removal planning. Here’s a lateral view.

image

The nail is located in front of the body of C2. It appears to be high enough to be near the pharynx, but well above trachea and esophagus. You can also see that the nail entered a little posteriorly, and travels right to left and forward. 

Here’s a representative CT slice.

image

The nail enters behind the carotids (just above the bifurcation) and IJ on the right, and ends anterior to them on the left. It passes very close to the posterior pharynx. So neurovascular structures are intact, and the aerodigestive tract is a maybe (back of the pharynx).

Obviously, this thing has to come out. The question is, how to do it? For you surgeons out there, tell me your choice of approach, incision, and instrumentation. Tweet or leave comments! Answers on Monday.

Related posts:

What Would You Do? Nail In The Neck

Here’s a very interesting case for you. A construction worker was carrying an object inside a building WHILE HOLDING HIS NAIL GUN! As he passed through the door, his elbow hit the frame and he brushed his neck with the business end of the gun. Guess what happened?

He experienced sharp pain, then noted pain every time he swallowed. He checked himself out in the mirror, and there was a small puncture wound in the right side of his neck. He presented to his local ED, with the complaints just noted. He was hemodynamically stable and neurologically intact. His airway was patent, and he had minimal pain. The following image was obtained. The nail measures about 6cm in length.

image

Let me know (by Twitter or comments) what additional information you think you need. I’ll discuss that tomorrow, then on Monday we’ll figure out what to do about this problem.

Related posts:

Why Do Trauma Patients Get Readmitted?

Readmission of any patient to the hospital is considered a quality indicator. Was the patient discharged too soon for some reason? Were there any missed or undertreated injuries? Information from the Medicare system in the US (remember, this represents an older age group than the usual trauma patient) indicates that 18% of patients are readmitted and 13% of these are potentially preventable.

A non-academic Level II trauma center in Indiana retrospectively reviewed their admissions and readmissions over a 3 year period and excluded patients who were readmitted on a planned basis (surgery), with a new injury, and those who died. This left about 5,000 patients for review. Of those, 98 were identified as unexpected readmissions. 

There were 6 major causes for readmission:

  • Wound (23) – cellulitis, abscess, thrombophlebitis. Two thirds required surgery, and 4 required amputation. All of these amputations were lower extremity procedures in obese or morbidly obese patients.
  • Abdominal (16) – ileus, missed injury, abscess. Five required a non-invasive procedure (mainly endoscopy). Only 2 required OR, and both were splenectomy for spleen infarction after angioembolization.
  • Pulmonary (7) – pneumonia, empyema, pneumothorax, effusion. Two patients required an invasive procedure (decortication, tube placement).
  • Thromboembolic (4) – DVT and PE.  Two patients were admitted with DVT, 2 with PE, and 1 needed surgery for a bleed due to anticoagulation.
  • CNS (21) –  mental status or peripheral neuro exam change. Eight had subdural hematomas that required drainage; 3 had spine fractures that failed nonoperative management. 
  • Hematoma (5) – enlargement of a pre-existing hematoma. Two required surgical drainage.

About 14% of readmissions were considered to be non-preventable by a single senior surgeon. Wound complications had the highest preventability and CNS changes the lowest. Half occurred prior to the first followup visit, which was typically scheduled 2-3 weeks after discharge. This prompted the authors to change their routine followup to 7 days. 

Bottom line: This retrospective study suffers from the usual weaknesses. However, it is an interesting glimpse into a practice with fewer than the usual number patients lost to followup. The readmission rate was 2%, which is pretty good. One in 7 were considered “preventable.” Wounds and pulmonary problems were the biggest contributors. I recommend that wound and pulmonary status be thoroughly assessed prior to discharge to bring this number down further. Personally, I would not change the routine followup date to 1 week, because most patients have far more complaints that are of little clinical importance than compared to 2 weeks after discharge.

Reference: Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma 72(2):531-536, 2012.

What To Do About The Nasty Patient

We’ve all taken care of them. The nasty patient. Sure, trauma can ruin one’s day. And a person can’t be expected to be on their best behavior after, say, a major car crash. But after the dust settles and the patient is recovering, we sometimes get a glimpse of their real personality. And sometimes, it turns out, they are just not really that nice.

Most patients don’t realize that being nasty to their caregivers creates problems for themselves. Yes, we are trauma professionals, and we should be able to take care of anybody, anytime, under any circumstances. But human nature is what it is. We unconsciously try to minimize discomfort. And this may mean unconsciously reducing cares and interpersonal communication with the offensive individual.

The most important thing we can do is to make sure that the patient is aware that their behavior is not acceptable, and to set strict limits. A tight feedback loop is important. Equally as important, every provider needs to have the same limits, so the patient can’t play them against each other, trying to manipulate the system. Often times, the mere fact that the patient knows that the entire team has a uniform set of limits and expectations can help shape their behavior. This lets them recover as quickly as possible, and get out of the hospital at the earliest opportunity.

How can we accomplish this? Our hospital has developed a sort of “behavioral contract” that is provided to potential problem patients (and their visitors/families) to shape behavior before it has a chance to deteriorate. Nurses and/or doctors review the contract with the patient, explaining each point. They are them asked to sign, but even if they refuse, they are told they are still bound by it. Every trauma professional involved knows the limits so there is no room for manipulation. Here’s a copy of ours:

Have a look at our behavioral contract, and let me know your thoughts, or share the tools and tips you use to deal with this issue.

Download the behavioral contract here