Archive | January, 2014

Stabbed in the chest…

January 29, 2014


This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

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Interesting finding on “Pan Scan”…

January 24, 2014


The trauma “Pan Scan” has been a controversial topic for a while now.  “Pan Scan” has multiple meanings but is usually some combination of head, c-spine, chest and abdomen CT imaging to identify serious traumatic related injuries.  Downsides include cost, radiation, and contrast.  Upsides include early identification of serious trauma including solid organ injuries.  Here is an interesting case that presents an original argument for the “Pan Scan:”

Pills in skin folds 2 Pills in skin folds

This person came in with altered mental status and trauma (single car MVC).  CT identified a large number of hidden pills later identified as an opioid pain medication.  They were hidden in an abdominal fold just above the pubis!

(Disclaimer:  Please don’t misinterpret this as an argument to identify pills with a pan scan.  It would have been much more cost effective to find them on physical exam)

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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I think I got stabbed in the eye…

January 18, 2014


Patient presented after an altercation.  He thinks he got stabbed in the eye with a “razor blade or a pencil.”  Eye was swollen shut and unable to be opened due to significant edema:

Pencil orbit 1 Pencil Orbit 2

This patient has a radioopaque foreign body just lateral to the globe.  It is penetrating into the posterior orbital fossa but doesn’t appear to be causing proptosis or retrobulbar hematoma.  It does indeed look like a pencil!

Author:  Russell Jones, MD

Image Contributor:  Ken Kelley, MD

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WWWTP #13 Answer

January 8, 2014

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A few days ago I posted arm xrays of a patient who injected himself with an unknown substance: 


The images show a radioopaque substance that appears to be tracking up the arm.  It is consistent with a liquid metallic substance. 

This person injected themselves with mercury.

Liquid metallic mercury is a toxic substance that can cause localized sterile abscesses when injected.  It rarely causes systemic toxicity but it is recommended to washout the injected site to avoid further systemic absorption.  Significant mercury toxicity is usually seen with inhalation of mercury vapor resulting in brain, kidney, and lung damage.  Some case reports of mercury injection are available in the literature, please see this article published in 2004:

Image Contributor:  Ian Julie, MD

Author:  Russell Jones, MD


1.  Prasad VL.  Subcutaneous Injection of Mercury:  “Warding Off Evil.”  Environ Health Perspec.  Sept 2004; 112(13): 1326-28.

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WWWTP #13 (What’s Wrong With This Picture?)

January 3, 2014

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This patient presented with suicidal thoughts…he says he injected something into his arm.


What’s wrong with this picture? 

Answer to follow.

Image Contributor:  Ian Julie, MD

Author:  Russell Jones, MD

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