Category Archives: General

How To: Deal With Fence Impalement (Part 3)

The patient impaled himself in the thigh while climbing over a wrought iron fence. A section of the fence (including him) has been carefully been separated, and it’s been secured while he is loaded into the ambulance. He’s just been dropped at your emergency department. What to do?

Trauma team activation? Yes! This should have been called in advance so the team could assemble prior to the patient’s arrival. This will definitely require a team, and the surgeon will be essential in planning further care.

Sedation? Definitely! If the embedded object is unwieldy or causes much discomfort, even consider electively sedating and intubating the patient for ease of management without causing more pain.

OR activation? Yes! Even before the patient arrives, the surgeon should call the OR to ready a room, since this will almost certainly require surgical attention.

ATLS guidelines? Yes! This case presents a perfect example of the Dang! factor (see below). Don’t let the team focus attention on the dramatic problem while ignoring his impending airway obstruction or some other major problem. A good physical exam of the involved part is essential to detect any subtle neurovascular symptoms that may give clues to deeper injuries.

Imaging? Maybe. Only if it will provide information that would help guide the extraction process. Just remember, it’s iron. Most radiographs and any MRI will be significantly degraded by so much metal.

The top left bar was in the groin crease, the middle left bar pierced the back of the thigh. There were no vessels or nerves involved.

Extraction in OR? Almost always! Only the smallest object embedded in the most benign areas can be removed in any place other than the OR. Depending on how close the foreign body is to any vital structure, the surgeon needs to decide whether to cut down on the object vs sliding it out and watching for the consequences (bleeding). Tourniquets may be used in more distal areas (not this case, though, due to how proximal it is).

Related posts:

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How To: Deal With Fence Impalement (Part 2)

In the last post, I discussed a patient who had impaled himself on top of a wrought iron fence.The questions revolved around proper management in the field. Here are my thoughts.

First of all, the patient stays impaled until delivered to the hospital. This will require a fair amount of creativity, as outlined by the comments by Medic97 in my last post. There are two main components: extrication and transport. The two are closely related.

Extrication will require some heavy equipment not carried by your typical EMS prehospital providers. The fire department or other agency can bring the equipment to the scene. I’ve actually seen rescue teams raid nearby construction trailers for tools!

It then boils down to finding the best spots to cut the fence while protecting the patient. Cutting equipment vibrates, gets hot, and can potentially cause abrupt movements of the fence. Shielding or bracing appropriate to the type of equipment being used is very important. Analgesia and sedation are encouraged. And once the piece of fence is detached, moving it and the patient in unison takes quite a few people.

The last challenging task is getting the patient into the rig (transport). Make sure that the section of fence removed will actually fit through the rear door while attached to the patient. If this is a problem, it’s easy to trim off sections at this point to allow a fit. The other difficulty is securing the patient for the ride, mainly because they may not be able to assume the usual supine position. I’ve seen patients who had to be transported on their side or even prone because of the orientation of the foreign object. Once again, creativity is the key!

Finally, call ahead and notify the emergency department. This will allow them to plan ahead for positioning and imaging needs, and will let them get an OR ready for eventual removal of the object.

The fence posts went over and under the right femur, with the lower one impaling the posterior thigh and the upper one resting on the groin.

Tomorrow, I’ll finish with some tips you can use once the patient arrives at the hospital.

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How To: Deal With Fence Impalement (Part 1)

The first part of this post is for my prehospital colleagues. We’ve probably all seen one of these at least once. Someone decides that want to take the short cut. Over a wrought iron fence. Alcohol is usually involved. They get to the top, but just before they can get over, they slip. The top of the fence impales their thigh!

This example comes from a TV news site in Los Angeles.

Let’s say you are one of the first responders at the scene. What do you do? Pull him off or leave him impaled? What equipment do you need? How do you avoid further harm? How do you fit him into your rig? How do you even secure it? Tweet you answers or leave comments below.

I’ll share some of my ideas on Monday, as well as the xray. Then we’ll talk about the in-hospital management piece. 

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New Technology: Artificial Bones

Most orthopaedic injuries are very handily fixed by our friendly neighborhood orthopaedic surgeons. But occasional patients have bony injuries so severe that they challenge even the best of them. Think motorcycle crashes, mangled extremities and bone loss.

Researchers at universities in Edinburgh and Southampton have developed an experimental product that may facilitate rebuilding these challenging injuries. They created a plastic polymer that is honeycombed with small holes. These holes allow blood to flow through it, enabling stem cells from the bone marrow to take up residence and rebuild bone. Once new bone has formed, the plastic slowly degrades, leaving only the patient’s own tissues.

This image show proteins from skeletal stem cells that have been cultured on a plastic scaffold

This new product has been tested successfully in animals, and work is underway to get approval for human testing.

Bottom line: Although many years away, this product may increase the number of limbs salvaged after mangling type injuries to the extremities.

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Reference:Discovery and Evaluation of a Functional Ternary Polymer Blend for Bone Repair: Translation from a Microarray to a Clinical Model.  Advanced Functional Materials ePub Jan 25, 2013.

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The 8 Hour Rule For Open Fractures: We’re So Over That

For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.

A paper being presented at the AAST meeting in Chicago next week retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.

They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.

The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.

Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.

Refresher on the Gustilo classification system:

  • Class I – open fracture, clean wound, <1cm laceration
  • Class II – clean wound, laceration >1cm with minimal soft tissue damage
  • Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
  • Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
  • Class IIIC – arterial injury without regard for degree soft tissue injury

Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.

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