Image of the Day 30: Coin Ingestion in 7 months Old Infant

A 7 months old infant alleged ingestion of 5 cents Malaysian coin while reaching it with his hand. He otherwise do not have any respiratory distress. Examination shows a healthy and active infants with normal vital sign. No stridor or other noisy breathing. X ray shows coin inside the esophagus.

Discussion

1. Always obtain a lateral view radiological image to identify the exact location of foreign body. An AP image is usually misleading and not helpful.

2. Esophagus is anatomically posterior to the trachea and usually appears as a ‘collapse’ tube in the lateral neck x ray.

3. Most of the foreign body will enter the gastrointestinal tract rather than airway tract due to protective mechanism of glottis.

4. Always suspect a foreign body ingestion in an infant with capabilities of reaching out object or ambulating who presented with noisy breathing.

5. Foreign body esophagus usually stuck in three normal anatomical narrowing position, 1) Upper esophageal stricture, 2) crossover of the aorta and 3) Lower esophageal stricture.

6. blunt foreign body in gastrointestinal tract can be managed conventionally except for sharp object and multiple magnet ingestion. Serial x ray can be taken based on clinical judgment and it is important that the foreign body already pass the ileo-cecal junction.

Image of the Day 29: Second Degree Burn of the Right Upper Limb and Anterior Lateral Chest Wall

18 months old baby girl was brought by the mother because of alleged hot water splashed over the right side of upper trunk 12 hours prior to presentation.

The picture shows second degree burn of the right upper limb with anterior lateral chest wall. Ruptured Bullae was seen at anterior cubital fossa and near the axillary fold. Wounds appear dirty.

Even though it is only 3% TBSA, it is considered as major burn as overlie the major joints.

Image of the Day 28: Needle Ingestion

A 12 years old boy who was playing with needle accidentally ingested it and was brought to casualty by the parent because of neck pain. He otherwise did not develop any sign of airway obstruction.

Radiological imaging shows a needle inside the trachea.

Foreign body that has being ingested usually pass spontaneously throughout gastrointestinal tract without any complication except for less than 1% of population. Sharp object may associated with perforation of the stomach or bowel. Retained foreign body may cause gastrointestinal erosion or abrasion and leading to bleeding.

Zeynep Ozkan et al, (2011) reported an interesting case of needle migratory. On the serial X ray imaging, the needle was seen to pass the terminal ileum and transverse colon but somehow migrated to thorax and settle down in lower lobe of the left lung. Meanwhile Mesut Bulakci et al (2011) reported a case of needle ingestion that migrate to liver.

 

Image of the Day 25: Open Chest Wall with Open Pneumothorax

28 year old gentleman was brought to casualty after alleged assaulted by a known person with “parang”. Upon arrival, he was fully conscious but drowsy, pallor, with clothes and bandage soaked in blood. Blood pressure was not recordable but radial pulse was palpable with very low volume and tachycardia. Heart rate at that time was 124. Patient still having spontaneous breathing with oxygen saturation on air was 90% but improved to 100% with high flow mask 15L/min.

A primary survey revealed intact airway and breathing, a large incised wound measuring 30 cm at the right posterior medial aspect of the back with traumatic incision of the right posterior inferior lobe of the lung, and multiple laceration wound over the back, and defensive wound at right palmar of hand, left hand first web space.

Patient was resuscitated with 2 pints of normal saline, 1 packed cell, 1 whole blood and four unit of fresh frozen plasma. Haemostatic suturing of the open chest wound was done and chest tube was inserted at safety triangle. Other wound was irrigated and haemostatic suture was applied. Blood pressure picking up to 120/73 and remain stable. IV Fentanyl was given as analgesia and patient was covered with IV Cefuroxime and sent to operation theater for definitive management. 

30 cm deep incised wound at the right posterior medial aspect.

incised wound of the posterior inferior lung lobe

Discussion

Before we proceed, let us recall the algorithm in trauma life support. “ABCDE”, A is for airway and cervical protection, B is for breathing and ventilation, C is for circulation and bleeding control, D is for disability and E is for exposure and environmental factor.

In primary survey, we should play an attention to the condition that will kill the patient immediately if no intervention done. The mnemonic as being taught by all the emergency physician is ATOM FC which describe 1) Airway obstruction, 2) Tension pneumothorax, 3) Open chest wound / Open Pneumothorax, 4) Massive hemothorax, 5) Flail chest and 6) Cardiac temponade.

Patient should also be look for the Hidden 6 usually in secondary survey. Hidden six which being describe by mnemonic PATMET will resulting in patient death if being discharge home or improper disposal. It includes 1)Pulmonary contusion, 2) Aortic disruption, 3) Tracheobronchial disruption, 4)Myocardial contusion, 5)Esophageal trauma, and 6)Traumatic diaphragmatic rupture.

This case explain about open pneumothorax. A quick diagnosis should be made during the primary survey and fast intervention should be provided.

In normal physiology, air will enter the lung  during inspiration due to negative intra thoracic pressure. When there is a chest wall defect especially if the size of the hole is more than 0.75 times the size of trachea. The reason is that, the chest wall defect is shorter than trachea, providing less resistance to flow.

As the air enter the pleural space, a tension may develop especially if the flap is created, allowing the air to come in but not out. This will resulting in inadequate oxygentation and ventilation.

Oxygen delivery should be started with 100% oxygen via the non rebreather mask. Any failure to oxygenation or ventilation require intubation. An open wound must be closed with a seal and a chest tube must be inserted urgently.

if there is no chest tube and proper seal especially during the field assessment, a  cover with three sided tape can be applied which act as a valve, allowing the air to escape from the pneumothorax during inspiration but not to enter during the inspiration.

After stabilization, complete secondary survey must be done and patient should be sent for definitive management in operation theater.

Reference:

1) http://www.trauma.org/archive/thoracic/CHESTopen.html

2) Shirley Ooi

Image of the Day 22: Laceration Wound of Scrotum

12 year old boy alleged fall while he wanted to jump into a river from a floating log. He eventually smashed his testes to the log surface. He sustained pain at the testicular region and noted some bleeding which stop upon compression. No loss of consciousness, no abdominal pain and no passing out of bloody urine.

Examination of the testis reveals laceration wound of testis exposing the external spermatic fascia. He was lucky that no damage to the testis occur and no skin loss.

IV line was inserted and he was given pain killer. The exposed wound was irrigated with normal saline and the testis was covered with wet gauze before he was sent for emergency wound exploration followed by wound toilet and suturing.

Revision: Layer of Testis

1. Scrotum

Skin

Superficial fascia with dartos muscle

2. External spermatic fascia (from external obliques muscle)

3. Cremaster muscle

4. Internal Spermatic Fascia (from transversus abdominis muscle)

5. Tunica vaginalis parietal (from peritoneum)

6. Tunica vaginalis visceral

7. Tunica albuginea and testis.