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Under sedation, the knife can be smoothly withdrawn.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.

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.

This post is for my readers located near large bodies of water!

Personal watercraft use exploded a decade ago, and they are still heavily used for recreation and vacation fun. However, speed and people don’t always mix well. Here’s an interesting case to ponder.

An 18 year old woman was the rear passenger on a jet ski traveling at a high rate of speed (of course). She fell off and was plucked out of the water by the driver. After riding for another 30 minutes, they headed to shore. A short while later, she began experiencing vague lower abdominal discomfort. This slowly progressed throughout the afternoon, becoming more severe.

She presents to your ED, looking uncomfortable and slightly ill. Here are some questions to ponder:

• What injuries are you concerned about?
• What diagnostics are appropriate?
• If surgery is required, what are the appropriate approaches and procedures?

Please comment below, or tweet your thoughts. Answers tomorrow!

No correct guesses yet, but some good tries! Remember, this was a 16 year old male who crashed a motorcycle and sustained liver and spleen injuries. A month after successful nonoperative management, he presents with a single episode of hematochezia. 

Here’s a CT scan taken during the second ED visit:

What’s the problem? Any way to have detected it sooner? What to do now?

Comment or tweet your answers!