Tag Archives: what the heck?

What The Heck?! The Answer!

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!

What The Heck?!

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.

What The Heck? CT Imaging Problem: The Answer

I received some good guesses about this image yesterday, but no one got the right answer.

The patient had sustained blunt trauma and was undergoing CT imaging. The scout for the abdominal CT showed some kind of weird debris that interfered with the image, but when we uncovered and looked at the patient, nothing was visible:

What the heck? If you look carefully at the left side of the image, you can see that the “debris field” is on the surface of the patient. We can’t see in 3-D on images, but the difference in appearance on the left and right sides looks like it this stuff is wrapping around the patient.

She was brought in by EMS with a warming blanket in place. On closer inspection, this was a thin, disposable blanket that heats up when removed from an airtight plastic pouch. These blankets contain thin pockets of a mineral mixture that looks like gravel. When exposed to air it heats up.

But on CT it looks like bone density material! When we looked at the patient, we were just lifting off the blanket that contained the offending material. Hence, we couldn’t find it.

Here’s a picture of one of these products. Note the six mineral pouches embedded in it., Don’t let this happen to you!

 

What The Heck? CT Imaging Problem

Here’s one for you. A patient is brought to you after a motor vehicle crash. You’ve completed your evaluation in the trauma resuscitation room, and you move off to CT for some imaging.

As the techs are preparing to do the abdominal CT, they perform the scout image to set up the study. This is what you see:

The arm was left down due to a fracture (note the splint along the forearm). But what is all that debris on the image? Other than a few abrasions here and there, nothing is visible on the skin in those areas.

What the heck? What do you think these are? Will they interfere with imaging? And what can you do about it?

Tweet or comment with your answers. I will explain all tomorrow.

What The Heck? Pigtail Catheter Chest Tube – The Answer

I previously described a trauma patient who had a pigtail type chest tube inserted with some odd CT findings after insertion:

So what is wrong in this picture? Well, the catheter has been inserted into the spleen! This can occur if it is inserted too low, or if there are adhesions between lung and chest wall or diaphragm.

How can it be avoided? Make sure that the insertion point is no lower than the 5th intercostal space. This is the level of the nipple in a male. And depending on what type of kit you use, be careful! Some are based on Seldinger technique, which would seem to be a bit safer. Others use a small trochar, which can be inserted a little too deeply at times. Note that this complication can occur with any kit, and can also occur when using a standard tube and open insertion technique.

Does a pigtail tube even work for hemothorax? There’s some debate about this. Traumatic hemothorax is not defibrinated like a medical one. Thus, there are frequently clots present which may not fully evacuate through a standard chest tube, let alone a tiny one. Thus, I don’t recommend a pigtail for acute traumatic hemothorax.

How should I manage this issue? Obviously, this tube needs to come out. And assuming that the initial indication for the tube is still present, a better one needs to be inserted. Dont’ pull it out yet! First, look at the vital signs. If there is significant bleeding and/or vitals are not normal, an immediate trip to the operating room is in order. In this case, the patient will likely lose their spleen.

If vital signs are stable, book both an interventional radiology suite and an OR. Or better yet, use a hybrid room. Have the radiologist obtain a baseline angiogram, and position a catheter in the main splenic artery. Incrementally remove the pigtail, hand injecting a small amount of contrast each time. If extravasation is noted at any time, the radiologist can then attempt to embolize. If selective embolization isn’t successful, then the main splenic artery should be embolized. If embolization doesn’t work, or vital signs deteriorate at any time, the surgeon should immediately proceed to laparotomy. Attempts at splenic salvage will probably not be successful.

Finally, insert a new, conventional chest tube using finger guidance. Don’t make the same mistake twice! And by the way, this works for pigtails in the liver, too. They are less likely to bleed significantly when withdrawn, and obviously the radiologist can only used selective embolization if they do.