March Case of the Month

Case of the Month

March 2017

Deep in the wilderness of Canada there once lived a lumberjack. He was about 35-years-old and loved his axe. One evening at the local eatery he was enjoying an ice cold beverage and was bragging about how strong he was and how he could chop through ANYTHING. After that the challengers started lining up to best the lumberjack.

The first person put down his steel toed work boots, CHOP, right through. The lumberjack laughed.

A second person brought him a 1000-year-old log, the lumberjack set down his glass, CHOP, right through. "Is that all you got?" uttered the lumberjack.

The third person was actually a retired lumberjack himself and set down his axe. The lumberjack looked at it, torn in his heart about destroying another man's axe or defending his honor, he hesitated for a moment then CHOP. The sound was deafening and the first lumberjack crumbled to the ground in a pool of blood.

EMS brings the lumberjack into the trauma bay. The nurses & doctors complete the primary survey. Airway intact, lungs clear bilaterally, 2+ pulses throughout, GCS 15, and then removed all the clothing to find a horizontal wound ~1cm in length over the left lower anterior chest wall just above the costal margin. The lumberjack was rolled and there were no other wounds. 

His vitals were all within normal limits, 2 large-bore peripheral IVs were already established and blood was sent. The secondary survey was completed and noted to have a soft and nontender abdominal exam. 

While X-Ray was getting ready a FAST exam was performed.


Hover for interpretation

FAST Exam Interpretation

No free fluid in Morrison's pouch (RUQ), splenorenal recess (LUQ), or pelvis. No pericardial effusion.

FAST: negative for free fluid in abdomen and pericardium

XRay:  Cardiac silhouette not enlarged. Lungs clear and no opacities. No PTX, no pleural effusion. No rib fracture. Rounded radiopaque density noted overlying the anterior inferior chest wall. Radiolucent density surrounding this area is likely from the gas bubble in the stomach and an accompanying laceration. 

The question becomes does this patient need a CT?

Hold that radiation!

Clinically it is not in the thoracic cavity or abdominal cavity based on CXR, FAST, and the patients exam. But don't we all feel better when we know exactly WHERE that piece of whatever it is IS? Of course.

Ultrasound to the rescue. Using a high frequency linear probe you can pick up foreign bodies in the soft tissue and confirm your diagnosis in 10 seconds. Or 6 seconds (depending on your clip length). 

Based on this ultrasound you can see a rounded hyperechoic (bright white) structure with posterior reverberation artifact located within the pectoralis muscle. Just deep to this you can also identify what looks like the heart coming in, but lung pulse could also appear this way. Either way the foreign body is still located superficially. You can even measure the depth using the caliper tool on the machine, which comes out to ~0.9cm in depth. 

The lumberjack did really well. Labs and vitals remained normal. He was observed in the ED and then after a short period of time he was released back into the wilderness... of Canada. He is still chopping down trees to this day, and he learned a very valuable lesson. Listen to your GUT instinct or get shot in the gut (or chest... or wherever) and more importantly never ever come between a man and his axe.