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.

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!

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.