CORRESPONDENCE Spontaneously Expectora ted Penetrat ing Foreign Body

To the Editor: The behavior of penetrating foreign bodies frequently is

unpredictable.1 Bullets have been reported to settle in near- ly every body cavity, as well as in the vascular system and some hollow viscera. They rarely leave the body spon- taneously.

A 28-year-old man presented to the emergency depart- men t minutes after being struck in the throat by a fragment of a wedge he was using to split firewood. A friend had been striking the wedge with a large sledge hammer at the time of the accident.

On admission the patient appeared anxious but in no res- piratory distress. His vital signs were as follows: blood pres- sure, 138/94 m m Hg; pulse, 80; and respirations, 16. Phys- ical examination of the neck revealed a 0.5-cm laceration just inferior and lateral to the cricothyroid membrane. Crepitus was present at the wound site. No hematoma or bruit was present, and the patient had a normal voice. Breath sounds were clear bilaterally; the remainder of the physical examination was within normal limits.

Joseph F Waeckerle, MD, FACEP - - Editor Kansas City, Missouri

Soft-tissue radiologic examination of the neck revealed a small amount of prevertebral and anterior fascial air. No for- eign body was seen. Because of the patient's urge to cough and the apparent absence of the fragment, an upright pos- teroanterior and lateral chest radiographs that demonstrated a radiopaque foreign body just distal to the left mainstem bronchus were obtained (Figure).

Shortly after returning to the ED the patient expectorated a 1 x 0.5-cm piece of jagged metal. A repeat chest radiograph failed to demonstrate the previously identified object. He was admitted to the otolaryngology service, where indirect laryngoscopy was performed with the finding of only blood- tinged vocal cords. The patient was discharged the follow- ing day after receiving intravenous penicillin G and a tet- anus immunization. He continued to do well on his follow- up examination two weeks later.

Penetrating foreign bodies, including bullets and shotgun pellets, frequently follow bizarre trajectories in the soft tissues. By far the most commonly reported misadventures involve bullets that have become vascular emboli producing occlusive complications in the extremities and the brain.l, 2 In addition bullets have lodged in the bladder, pericardium, peritoneum, and pleura, where they may remain without complication or incite serious inflammation. 3-s One bullet was voided spontaneously. 6 It is rare for bullets to lodge in major airways, particularly through the chest, and even less common for them to be expectorated, z-9

This unusual case of airway penetration by a foreign body

serves, however, to illustrate typical problems associated with this in ju~ When faced with a penetrating injur~, it is not uncommon to have difficulty locating the foreign body radiologically, A thorough search should be made for an exit wound, and radiographs of surrounding structures should be taken with the realization that the location of the foreign body tells little of the actual pathway it may have taken. Exploratory surgery and invasive diagnostic studies should be evaluated carefully before being implemented. One re- ported patient underwent laparotomy for a gunshot wound t o the chest with the bullet localized radiologically near the stomach3 At surgery the bullet was found floating inside the stomach, which appeared to have suffered no injury. This case is the only one found in a careful literature search of a penetrating foreign body to the trachea and subsequent spontaneous expectoration.

Paul Roth, MD Division of Emergency Medicine University of New Mexico School of Medicine Albuquerque, New Mexico

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Benjamin Diven, MD Department of Emergency Medicine Memorial General Hospital Las Cruces, New Mexico

1. Ledgerwood AM: The wandering bullet. Surg Clin North Am 1977;57:97-109.

2. Alsofrom DJ, Marcus NH, Seigel RS, et al: Shotgun pellet em- bolizati0n from the chest to the middle cerebral arteries. J Trau- ma 1982;22:155-157.

3. McLaughlin JS, Herman R, Scherlis, L, et al: Sterile pericar- ditis from foreign body: Acute tamponade one month following gunshot wound~ Ann Thorac Surg 1967;3:52-56.

4. Abbot J: An !ntrapericardial tumbling bullet. JAMA 1973;223: 196. 5. Eickenberg HU, Amin M, Lich R: Traveling bullets in geni- tourinary tract. Urology 1975;5:224-226. 6. Cohen SP, Varm a KR, Gouldman SM: Spontaneous expulsion of intravesicular bullet. Urology 1975;5:224. 7. Peterson TA: The case of the tussive thief. JAMA 1968;204: 174-175.

8. Symbas PN, Hatcher CR, Boehm GAW: Acute penetrating tra- cheal trauma. Ann Thorac Surg 1976~22:473-477. 9. Bogedain W: Migratio n of schrapnel from lung to bronchus. ]AMA 1984;251:1862-1863.

latrogenic Digital Ischemia To the Editor:

The use of tubular bandages for the dressing of finger and toe wounds is common practice in many emergency depart- ments, outpatient clinics, and operating rooms. When prop- erly applied, these bandages form a convenient dressing with some splinting capability. When improperly applied, however, they may lead to ischemic injury and possibly ne- crosis of the digit.

A 21-year-old man sustained a severe crashing injury to the distal tip of his right middle finger when he placed his hand under an operating rotary power motor. He was seen in an ED approximately one hour later. Two lacerations were noted, one of which extended through the nail into the proximal portion of the nail bed. Neurovascular and tendon examination showed no evidence of trauma. Roent- genograms of the hand showed a comminuted fracture of the distal tuft with adequate alignment.

After digital block with 1% lidocaine without epineph- rine, the finger was profusely irrigated and cleansed with povidone-iodine and saline. The damaged nail was removed. Lacerations to the skin and nail bed were repaired with 5-0 nylon and 6-0 vicryl sutures, respectively. A nurse was in- structed to place a petroleum jelly gauze dressing over the lacerations and an elastic tubular dressing over the gauze dressing. The patient was not given antibiotics, and no mention was made in the chart of whether he had had a tetanus booster shot. Before being discharged from the ED, he was provided with full verbal and written instructions for elevation of the hand and wound care, and he was cau- tioned about allowing ischemia to develop.

On the fourth day after the accident, the patient was seen by an orthopedic surgeon. He said that his finger had been severely painful since the bandage was applied. The orthopedic surgeon removed seven layers of an elastic tu- bular bandage, which he described as being "tight" around the finger. Distal to the midportion of the proximal pha- lanx, the finger was markedly swollen in a well-demarcated line consistent with the proximal margin of the tubular dressing. The digit, was anesthetic on the sixth day, and the tip was gangrenous by the thirteenth day (Figure). On the fourteenth day, the digit was amputated at the level of the midproximal phalanx. The pathology laboratory reported

finding necrosis, gangrene, and subacute inflammation of the amputated digit.

A computerized search (Medline) of the last 18 years of the English language medical literature yielded only two reports of ischemic complications secondary to the use of tubular bandages.

Miller and Haftel reported four cases of digital ischemia secondary to the misapplication of elastic-containing Sur- gifix ®. The dressings had been applied i n multiple layers with a twisting of the proximal end before the applicator was pulled distally to form another layer. Three of the four patients reported increased pain and swelling of the digit before the discovery of ischemic changes. One patient re- quired amputation. 1

Ersek reported a single case of digital ischemia and necro- sis resulting from the multiple-layered application of an elastic tubular dressing. The patient noted increased pain on the fourth day and required amputation of the digit on the sixth day. 2

Tubular bandages are available under various brand names from several manufacturers. There are two general styles of bandag e . One is cotton gauze tubing, which essen- tially is nonelastic. A representative example of this class of

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