Tag Archives: pop quiz

Pop Quiz! What’s Wrong In This Picture?

Here’s another one to challenge your skills! A young male presents to your ED after minor chest trauma with pleuritic chest pain and slight shortness of breath. A chest x-ray is obtained which shows a large pneumothorax on the right. You insert a chest tube, and the procedure goes well.

Another x-ray taken immediately after insertion looks like this:

The lung is not yet fully expanded, but the patient already feels better. 

What is wrong in this picture? Tweet or leave comments. Hints tomorrow if I don’t receive the correct answer.

Pop Quiz: CT Scanning After Gunshot To The Abdomen

Gunshots to the abdomen have a very high likelihood of causing damage that needs to be repaired. For this reason, the vast majority are immediately transported to the OR for laparotomy (celiotomy). 

But there are a few situations in which advanced diagnostics can be justified prior to operation. Do you know what they are? Tweet or comment your answers. I’ll explain the details tomorrow.

Pop Quiz! Final Answer

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Under sedation, the knife can be smoothly withdrawn.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.

Pop Quiz! The Case, Part 2

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.