Tag Archives: what the heck?

Answer: What The Heck Video! Part 1

Several of you figured this one out! The patient was involved in a high speed car crash and was brought to the ED in respiratory distress.  Decreased left sided breath sounds were noted. The following xray was obtained.

Opacity is noted in the left lung field, and a modest pneumothorax is seen on the right. Bilateral first ribs are fractured, and the left second through fourth ribs are also broken. The patient was intubated and bilateral chest tubes were inserted.

There was minimal blood from the left chest tube, and a small amount of air from the right. Note the extensive subcutaneous emphysema.

What should we do next? Are any other diagnostic tests indicated? Could the endotracheal tube placement be part of the problem?

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What The Heck? Answer!

The patient was a 27 year old intoxicated male who was uncooperative with police in France. The offending object is a Taser dart, which was fired at him for control. The dart was not noticed when he was released from custody, and he later presented to hospital with a headache! The dart was removed by a neurosurgeon and he was discharged uneventfully a week later.

Reference: A brain penetration after Taser injury: controversies regarding Taser gun safety. Forensic Science International, ePub 21 April 2012 ahead of print.

What The Heck? The Answer

The photo on Friday shows a woman who had been run over by her own car. The vehicle had rolled over her pelvis and stopped, requiring extrication. The most likely injury is an open book pelvic fracture with significant diastasis and/or bilateral unstable sacral fractures.

If you see this clinical presentation there are several things you need to do immediately:

  1. Call for blood. Losses will be large, so you may even want to consider activating your massive transfusion protocol.
  2. Call an orthopedic surgeon. External stabilization will be needed to help decrease blood loss.
  3. Consider early intubation for control of pain. You will be doing a lot, and a patient in agony will slow you down. Your patient is already hypovolemic, so plan your drug choices accordingly.
  4. Search for evidence of an open fracture. Do a good rectal and vaginal exam looking for blood.

The pelvic xray is poor quality, but shows the major problem, a 10cm pubic diastasis from the open book pelvis fracture. Wrapping the pelvis may be of some help, but consult your orthopedic surgeon first. This pelvis is probably not connected to the spine anymore, so wrapping may have variable results.