CA S E S T U DY
Management of Embedded Foreign
Body: Penetrating Stab Wound to
the Head
Sharolyn Martin, BSN, RN, CEN
Glenn H. Raup, PhD, MSN, RN, NE-BC
George Cravens, MD, FACS
Carrie Arena-Marshall, MSN, RN, NE-BC
■ ABSTRACT
Penetrating craniocerebral trauma is an injury in which a
projectile violates the skull but does not exit. The significance of penetrating injuries to the head depends largely
on the circumstances of the injury, the velocity of impact,
and attributes of the projectile. While most penetrating
head injuries are caused by firearms, lower-velocity mechanisms of penetrating brain injury present unique challenges for the multidisciplinary team involved with the
delivery of care. Appropriate management can lead to
optimal outcomes and limit secondary brain injury.
■ KEY WORDS
Embedded foreign body, Multidisciplinary approach,
Penetrating embedded trans-cranial trauma (PETT)
P
enetrating embedded trans-cranial trauma (PETT) is
an injury in which a projectile violates the skull but
does not exit. These types of injuries may be caused by
bullets or other sharp objects. Penetrating head injuries
may be the result of interpersonal violence, suicide
attempts, falls, motor vehicle crashes, or occupational
incidents. The significance of penetrating injuries to the
Sharolyn Martin, BSN, RN, CEN, is Emergency Department
Research Nurse, JPS Health Network, Fort Worth, Texas,
Glenn H. Raup, PhD, MSN, RN, NE-BC, is Assistant
Professor, DNP Program, Texas Christian University, Fort
Worth, Texas, George Cravens, MD, FACS, is Chairman of
Neurosurgery, JPS Health Network, Forth Worth, Texas, and
Carrie Arena-Marshall, MSN, RN, NE-BC, is ICU/RDU
Manager, JPS Health Network, Fort Worth, Texas.
Corresponding Author: Sharolyn Martin, BSN, RN, CEN,
1575 S Main, Ft Worth, TX 76104 (Smartin01@jpshealth.org).
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head depends largely on the circumstances of the injury,
the velocity of impact, attributes of the projectile, and the
location combined with the intracranial path of the object.
The focus of this article is on the management of
nonballistic PETT. Management of a penetrating injury
as a result of a transcranial embedded foreign object may
appear straightforward, but unique issues such as
formation of a traumatic pseudoaneurysm, vascular disruption with sudden exsanguination, limited visualization of cranial contents on computerized tomography
(CT) scan secondary to artifact from the impaled object,
and the development of infectious complications greatly
limit the establishment of universal treatment algorithms
to treat victims of transcranial trauma.
■ CASE REPORT
A 21-year-old Hispanic man was stabbed in the head
with a large butcher knife during an altercation at a bar.
He arrived at the hospital via emergency medical services
with the knife blade firmly embedded in his left temporal
bone just superior to the zygomatic arch. A Glasgow
Coma Scale (GCS) score of 15 was maintained during
transport as well as in the hospital. He denied any loss of
consciousness during the assault. The only deficit noted
during his primary and secondary assessments in the
emergency department was a probable injury to his left
eighth cranial nerve, demonstrating difficulty with closure of his left eye. After completion of the physical
assessment, a skull radiograph was taken (Fig 1). This
radiograph revealed the knife blade to be projecting over
the left orbit and extending into the left temporal fossa.
No definite fractures were appreciated.
A CT scan of his brain was performed emergently.
The CT demonstrated a large knife blade embedded
within the left skull traversing along the posterior aspect
of the left orbit within the anterior aspect of the left
middle cranial fossa, with the tip of the blade resting
near the cavernous portion of the left carotid artery. No
conclusive evidence of an associated intracranial or
extra-axial hemorrhage was noted. Extensive artifact
obscured the surrounding soft tissues (Fig 2).
April–June 2009
FIGURE 1. Plain skull radiograph-embedded transcranial
foreign object.
Arteriography of his cerebral arteries was obtained,
because of the proximity of the blade tip to the left
carotid artery, to determine the extent of cerebrovascular injury. The angiogram revealed no evidence of an
intimal injury, pseudoaneurysm, or extravasation,
showing normal bilateral internal carotid and cerebral
arteries (Fig 3).
Upon completion of all the necessary diagnostic
studies, he was taken to the operating room where he
underwent a left frontotemporal craniotomy with a craniotome. After the bone flap was removed, careful elevation and identification of the foramen ovale, foramen
rotundum as well as the superior orbital fissure was performed. After all structures had been identified, a 270
elevation of the dura mater around the knife was
attained. Dural bleeding from around the cavernous
sinus as well as a dural tear was noted in the anterior
portion of the temporal lobe. Dead tissue from the brain
was then carefully suctioned away, and the wound was
FIGURE 3. Standard cerebral angiogram without evidence of vascular injury.
FIGURE 2. CT scan demonstrating extensive artifact from
embedded knife.
irrigated with an antibiotic solution. The knife was then
removed cautiously by pulling in the same trajectory as
it had been inserted. After the knife was removed, bleeding was selectively controlled with bipolar electrocautery
and with gelfoam with thrombin. After approximately
5 minutes of direct surveillance of the cavernous sinus
region, no signs of excessive bleeding were noted from
the vessels in the area. Therefore, the area was rinsed
with antibiotic irrigation, and the dural tears were
repaired. The bone flap was replaced and then the
pericranial flap, temporal fascia, and skin were properly
positioned and the layered closure was completed.
The surgical procedure was tolerated well. The patient
was allowed to awaken from the general anesthesia in the
operating room. He was taken immediately for a postoperative CT scan and then transferred to the intensive care
unit (ICU) for close observation. He underwent 1 additional postoperative CT scan; neither of the follow-up
scans showed any signs of active intracranial bleeding.
He was discharged on postoperative day 3 without incident. He did not return for his follow-up appointment.
Because this injury resulted from an act of violence, the
surgical team was also responsible for the proper handling of forensic evidence. Once the knife was removed
from the cranial vault, a chain of evidence had to be
established and maintained. This was accomplished by
wrapping the knife in a towel of the operating room and
placing it in a large envelope, sealing it with patient stickers that had been timed, dated, and initialed, across the
seams. This envelope also cautioned that a sharp object
was enclosed inside for personnel safety. Appropriate
chain of evidence forms were completed and attached to
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83
the outside of the envelope before it was dropped in the
evidence collection safe. The appropriate law-enforcement agency was notified for later retrieval of the knife.
■ DISCUSSION
PETT comes with specific issues not associated with
blunt traumatic brain injury. This article does not
attempt to discuss the overall treatment of traumatic
brain injury such as managing increased intracranial
pressure; instead, it will present information particular to
penetrating head injuries. The scope is narrowed further
to look at treatment modalities as well as emergency,
perioperative, and intensive care nursing for nonballistic
penetrations that encompass retained transcranial foreign
objects.
Intracranial stab wounds are atypical, secondary to the
effective barrier provided by the adult skull. Nonmissile
penetrating craniocerebral injuries are generally easier to
treat than missile injuries. A stab wound creates a fine
hemorrhagic infarction that typically confines brain damage to the wound tract.1 Nonballistic penetrating head
trauma tends to occur at a lower velocity, which often
causes vital structures to be shifted aside rather than
obliterated.2 The prognosis for nonmissile PETT is good
in the absence of a laceration to one of the major
intracranial blood vessels with development of a subsequent massive intracerebral hematoma or direct injury to
the brainstem.
The usual areas of penetration are in the locality of the
orbits or in the temporal areas where the skull is thin.3
Temporal stab wounds are prone to major neurological
impairment as a result of the delicacy of the temporal
bone and the close proximity of vital structures and vasculature of the brain.4 Morbidity and mortality tend to be
higher from temporal stab wounds secondary to the
aforementioned reasons.
Emergency nursing considerations
The initial evaluation of an individual who has sustained
a transcranial injury should consist of a very thorough
physical examination as well as radiographic studies and
laboratory tests. The primary survey, assessment of the
patient’s airway, breathing, and circulatory status, is
always the foremost concern when dealing with PETT.
After ensuring patency and clinical stabilization of the
physiologic components of the primary survey, a meticulous neurological examination should be performed. A
detailed assessment should address the level of consciousness including documentation of the GCS, overall mental
status, cranial nerves, and motor/sensory function. A
comprehensive head-to-toe assessment should follow,
assuming that the patient is physiologically stable, evaluating all other systems. Specific attention should be given
to evaluation of the scalp. Oftentimes the penetrating
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object is absent at the time of assessment. Penetrating
wounds do not have usual sites or characteristic entry
wounds and are often buried beneath blood-matted hair.
Puncture wounds from objects such as ice picks are often
minute and easily missed, causing a delay in diagnosis of
a craniocerebral injury.
Once physiologic stability has been ensured, laboratory and radiological evaluations are vital to determining
the extent of injury. Initial laboratory evaluation studies
should include an arterial blood-gas analysis, complete
blood cell count, chemistry panel, type and crossmatch,
coagulation tests, and a drug screen including alcohol
level. Radiographic assessment may consist of a CT
scan, skull series, angiography, and magnetic resonance
imaging. Computerized tomography scans can detect the
path and location of the embedded foreign body, bone
and metal debris fragments, intracranial damage and
hematomas, and mass effect. While CT scanning is considered the gold standard for evaluation of intracranial
injury,5 it may be significantly blighted when a penetrating metal object is embedded in the cranial vault.
Because of the distortion, brain injury along the trajectory of the penetrating object may not initially be visualized. An immediate postoperative scan may be
warranted to look for missed contusion brain injury or
hemorrhage.6 CT scans are also necessary to evaluate
any changes in a patient’s mental status. Angiography is
advocated for initial evaluation of suspected cerebral
vascular injuries caused by PETT and to evaluate postoperatively for the presence of a pseudoaneurysm. When
ordering a diagnostic cerebral angiogram looking for
initial vascular injury with an embedded metal object, it
is important to specifically order a standard cerebral
angiogram as opposed to a CT angiogram. In these
cases, the standard angiogram allows for much higherresolution images because there is no artifact such as
would be seen with the CT angiogram. Magnetic resonance imaging is contraindicated in the presence of metallic fragments as the magnet may cause movement of the
projectile. A magnetic resonance imaging scan may
provide more detailed information than a CT scan for
penetrating nonmetallic foreign objects.
Perioperative nursing considerations
The most appropriate management for an embedded transcranial foreign object is to leave it in place until it can be
removed in a surgical suite under direct visualization.
Minimal manipulation of the embedded object prior to
removal maximizes the preservation of cerebral function
by avoiding additional tissue damage and sudden
exsanguination if the object is tamponading a major
vessel.7 Techniques employed to stabilize impaled objects
consist of taping, wrapping with sterile towels, suturing in
place, covering with a cup, and possibly cutting the
April–June 2009
embedded object down in size to decrease the likelihood
of accidental manipulation or removal.8
Embedded object removal may cause many problems,
as any movement during disimpaction may lead to further tissue or vessel damage with increased neurological
deficits. The individual may survive the initial injury, but
removal itself can lead to death. The impaled object
should be removed along its trajectory. Depending on the
location of the largest portion of the object, the foreign
body should be removed by either the antegrade or the
retrograde route following the trajectory of entry.9 In
PETT, the foremost purpose of surgery is to limit the possible complications that can arise immediately after the
removal of the embedded object.10 If the patient is stable,
it may be prudent to delay the surgical removal of the
object in order for the arrested bleeding secondary to the
tamponade effect to become consolidated and the injured
vasculature can develop a firm clot.9 When deemed
appropriate, the surgical procedure should be undertaken
to remove the embedded foreign body and to débride
necrotic tissue and clots followed by thorough hemostasis and dural closure.
injury to the brain. Factors correlated with seizures consist of severity of injury, retained foreign debris, and
hematoma formation.15,16 The neurological injury is
thought to cause a hyperexcitability of neurons with a
consequential formation of an epileptic focus.
Anticonvulsant prophylaxis administered in the immediate postinjury period is believed to curb neuronal hyperexcitability and reestablish the seizure threshold.14,17,18
Specific nursing interventions
Multiple concerns accompany victims of PETT in the
post–foreign body removal period. The primary concern is
the formation of a pseudoaneurysm. Rupture of traumatic
intracranial aneurysm occurs within 3 weeks after the
initial injury and carries a 50% mortality rate.11 As many
of these lesions are not visible on initial arteriograms and
have a high likelihood of future development, routine
angiography should be performed 7 to 14 days postinjury
on all patients.12 Another delayed complication is cerebral
vasospasm. It characteristically appears within the first
2 weeks postinjury, principally days 5 through 11.11 If not
treated promptly, the end result of either vasospasm or
pseudoaneurysm rupture is decreased cerebral perfusion
pressure. A continued state of cerebral hypoperfusion will
cause tissue hypoxia and cellular starvation with secondary neuronal injury, which carries a very poor prognosis.
Another customary complication that follows PETT is
infection. Cerebrospinal fistulas, meningitis, and abscess
are a few of the sources for infection. Bacterial contamination occurs in the wound as a result of dirt, bone fragments, or other foreign matter entering along with the
embedded foreign object. Organic materials, including
wood or bone, are more likely than inorganic projectiles,
such as glass or metal, to fragment and become infected
because of their porous nature.13 Additional latent infections may be composed of scalp infections, osteomyelitis,
and cerebritis. Tetanus prophylaxis and antibiotics may
avert these infectious complications.14
Posttraumatic epilepsy is relatively commonplace after
PETT. Seizures are thought to arise secondary to direct
Nursing interventions for patients with transcranial
embedded foreign bodies may be categorized by the following: (1) patient’s self-image, (2) family/loved-one
acceptance and perception, (3) physiologic management, (4) neurological function, and (5) multidisciplinary communication. The patient’s acceptance and
adjustments to the traumatic injury are of great importance to obtaining the maximum level of recovery.
Acceptance of disfigurement and physical limitation are
considerable obstacles to overcome. Nurses, by not only
caring for but also caring about their patients, initiate
the healing process through their own acceptance of
their patients’ appearance and physical condition. This
course of action begins with the preparation of the
patient of what to expect. Compassionate honesty in all
communications is vital to establishing a trusting bond
in the nurse-patient relationship.
In cases involving victims of embedded transcranial
objects, one of the most important details is making sure
the family sees the patient, providing his physical condition permits, prior to the surgical procedure. Nurses with
an expertise in dealing with this type of PETT recognize
the possibility of adverse events, including significant
changes in physical and neurological function and even
death, occurring during the extrication procedure. The
importance of the family seeing them just prior to the
operation cannot be overvalued. The patient/family needs
to be made aware of the possible complications involved
during the procedure to remove the impaled object and
be given the chance to discuss thoughts and feelings with
each other as well as with a healthcare professional to
answer questions. Nurses excel at this role because of
their ability to see the big picture without losing sight of
the smallest details.
To be an effective steward for a patient who has an
embedded transcranial foreign body, the nurse must not
only possess the knowledge of appropriate nursing care
of traumatic brain injury in general but also know the
nuances of physiological monitoring and care associated
with PETT, both nursing and medical. Nurses must be
vigilant in reviewing all previous orders to ensure that
they have been completed, in following up to be sure critical time-sensitive results have been posted, and in viewing current orders to be sure all the different disciplines
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Journal of Trauma Nursing • Volume 16, Number 2
Intensive care nursing considerations
85
are working cooperatively. This will ensure quality care
as it provides the foundation for recognizing even subtle
changes in their patient’s physiological condition that can
lead to secondary insult and further morbidity, if not
addressed in a timely manner.
Communicating with other team members in a clear,
concise, and professional manner ensures an optimal
chance for the best possible recovery. Reporting diagnostic results concerning physiological parameters unique to
penetrating injuries, as well as, changes and responses
to therapy is a continuum goal led by nursing.
Understanding the divergence between blunt and PETT
empowers nurses to bring different dimensions into
patient care.
■ CONCLUSION
Effective management of embedded transcranial foreign
objects necessitates an understanding of the mechanism of
injury and associated neurological pathophysiology. The
individual may survive the initial injury but later succumb
to death as a result of manipulation and/or surgical
removal of the impaled object or from delayed complications such as the rupture of a pseudoaneurysm or development of an infectious process. Optimal outcomes for
victims of PETT can be provided through a multidisciplinary approach incorporating medical, surgical, and nursing expertise. Nursing plays an integral role in ensuring
the best possible outcomes for patients who have sustained transcranial trauma. Nurses’ role as patient advocates ensures consistency throughout the multidisciplinary
continuum of care.
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