82 Journal of Trauma Nursing • Volume 16, Number 2 April–June 2009

Management of Embedded ForeignBody: Penetrating Stab Wound tothe 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

■ ABSTRACTPenetrating craniocerebral trauma is an injury in which aprojectile violates the skull but does not exit. The signifi-cance of penetrating injuries to the head depends largelyon the circumstances of the injury, the velocity of impact,and attributes of the projectile. While most penetratinghead injuries are caused by firearms, lower-velocity mech-anisms of penetrating brain injury present unique chal-lenges for the multidisciplinary team involved with thedelivery of care. Appropriate management can lead tooptimal outcomes and limit secondary brain injury.

■ KEY WORDSEmbedded foreign body, Multidisciplinary approach,Penetrating embedded trans-cranial trauma (PETT)

Penetrating embedded trans-cranial trauma (PETT) isan injury in which a projectile violates the skull but

does not exit. These types of injuries may be caused bybullets or other sharp objects. Penetrating head injuriesmay be the result of interpersonal violence, suicideattempts, falls, motor vehicle crashes, or occupationalincidents. The significance of penetrating injuries to the

Sharolyn Martin, BSN, RN, CEN, is Emergency DepartmentResearch Nurse, JPS Health Network, Fort Worth, Texas,Glenn H. Raup, PhD, MSN, RN, NE-BC, is AssistantProfessor, DNP Program, Texas Christian University, FortWorth, Texas, George Cravens, MD, FACS, is Chairman ofNeurosurgery, JPS Health Network, Forth Worth, Texas, andCarrie Arena-Marshall, MSN, RN, NE-BC, is ICU/RDUManager, JPS Health Network, Fort Worth, Texas.

Corresponding Author: Sharolyn Martin, BSN, RN, CEN,1575 S Main, Ft Worth, TX 76104 (Smartin01@jpshealth.org).

head depends largely on the circumstances of the injury,the velocity of impact, attributes of the projectile, and thelocation combined with the intracranial path of the object.

The focus of this article is on the management ofnonballistic PETT. Management of a penetrating injuryas a result of a transcranial embedded foreign object mayappear straightforward, but unique issues such asformation of a traumatic pseudoaneurysm, vascular dis-ruption with sudden exsanguination, limited visualiza-tion of cranial contents on computerized tomography(CT) scan secondary to artifact from the impaled object,and the development of infectious complications greatlylimit the establishment of universal treatment algorithmsto treat victims of transcranial trauma.

■ CASE REPORTA 21-year-old Hispanic man was stabbed in the headwith a large butcher knife during an altercation at a bar.He arrived at the hospital via emergency medical serviceswith the knife blade firmly embedded in his left temporalbone just superior to the zygomatic arch. A GlasgowComa Scale (GCS) score of 15 was maintained duringtransport as well as in the hospital. He denied any loss ofconsciousness during the assault. The only deficit notedduring his primary and secondary assessments in theemergency department was a probable injury to his lefteighth cranial nerve, demonstrating difficulty with clo-sure of his left eye. After completion of the physicalassessment, a skull radiograph was taken (Fig 1). Thisradiograph revealed the knife blade to be projecting overthe 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 embeddedwithin the left skull traversing along the posterior aspectof the left orbit within the anterior aspect of the leftmiddle cranial fossa, with the tip of the blade restingnear the cavernous portion of the left carotid artery. Noconclusive evidence of an associated intracranial orextra-axial hemorrhage was noted. Extensive artifactobscured the surrounding soft tissues (Fig 2).

C A S E S T U DY

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Arteriography of his cerebral arteries was obtained,because of the proximity of the blade tip to the leftcarotid artery, to determine the extent of cerebrovascu-lar injury. The angiogram revealed no evidence of anintimal injury, pseudoaneurysm, or extravasation,showing normal bilateral internal carotid and cerebralarteries (Fig 3).

Upon completion of all the necessary diagnosticstudies, he was taken to the operating room where heunderwent a left frontotemporal craniotomy with a cran-iotome. After the bone flap was removed, careful eleva-tion and identification of the foramen ovale, foramenrotundum as well as the superior orbital fissure was per-formed. After all structures had been identified, a 270�elevation of the dura mater around the knife wasattained. Dural bleeding from around the cavernoussinus as well as a dural tear was noted in the anteriorportion of the temporal lobe. Dead tissue from the brainwas then carefully suctioned away, and the wound was

irrigated with an antibiotic solution. The knife was thenremoved cautiously by pulling in the same trajectory asit had been inserted. After the knife was removed, bleed-ing was selectively controlled with bipolar electrocauteryand with gelfoam with thrombin. After approximately 5 minutes of direct surveillance of the cavernous sinusregion, no signs of excessive bleeding were noted fromthe vessels in the area. Therefore, the area was rinsedwith antibiotic irrigation, and the dural tears wererepaired. The bone flap was replaced and then thepericranial flap, temporal fascia, and skin were properlypositioned and the layered closure was completed.

The surgical procedure was tolerated well. The patientwas allowed to awaken from the general anesthesia in theoperating room. He was taken immediately for a postop-erative CT scan and then transferred to the intensive careunit (ICU) for close observation. He underwent 1 addi-tional postoperative CT scan; neither of the follow-upscans showed any signs of active intracranial bleeding.He was discharged on postoperative day 3 without inci-dent. He did not return for his follow-up appointment.

Because this injury resulted from an act of violence, thesurgical team was also responsible for the proper han-dling of forensic evidence. Once the knife was removedfrom the cranial vault, a chain of evidence had to beestablished and maintained. This was accomplished bywrapping the knife in a towel of the operating room andplacing it in a large envelope, sealing it with patient stick-ers that had been timed, dated, and initialed, across theseams. This envelope also cautioned that a sharp objectwas enclosed inside for personnel safety. Appropriatechain of evidence forms were completed and attached to

FIGURE 1. Plain skull radiograph-embedded transcranial

foreign object.

FIGURE 2. CT scan demonstrating extensive artifact from

embedded knife.

FIGURE 3. Standard cerebral angiogram without evi-

dence of vascular injury.

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the outside of the envelope before it was dropped in theevidence collection safe. The appropriate law-enforce-ment agency was notified for later retrieval of the knife.

■ DISCUSSIONPETT comes with specific issues not associated withblunt traumatic brain injury. This article does notattempt to discuss the overall treatment of traumaticbrain injury such as managing increased intracranialpressure; instead, it will present information particular topenetrating head injuries. The scope is narrowed furtherto look at treatment modalities as well as emergency,perioperative, and intensive care nursing for nonballisticpenetrations that encompass retained transcranial foreignobjects.

Intracranial stab wounds are atypical, secondary to theeffective barrier provided by the adult skull. Nonmissilepenetrating craniocerebral injuries are generally easier totreat than missile injuries. A stab wound creates a finehemorrhagic infarction that typically confines brain dam-age to the wound tract.1 Nonballistic penetrating headtrauma tends to occur at a lower velocity, which oftencauses vital structures to be shifted aside rather thanobliterated.2 The prognosis for nonmissile PETT is goodin the absence of a laceration to one of the majorintracranial blood vessels with development of a subse-quent massive intracerebral hematoma or direct injury tothe brainstem.

The usual areas of penetration are in the locality of theorbits or in the temporal areas where the skull is thin.3

Temporal stab wounds are prone to major neurologicalimpairment as a result of the delicacy of the temporalbone and the close proximity of vital structures and vas-culature of the brain.4 Morbidity and mortality tend to behigher from temporal stab wounds secondary to theaforementioned reasons.

Emergency nursing considerationsThe initial evaluation of an individual who has sustaineda transcranial injury should consist of a very thoroughphysical examination as well as radiographic studies andlaboratory tests. The primary survey, assessment of thepatient’s airway, breathing, and circulatory status, isalways the foremost concern when dealing with PETT.After ensuring patency and clinical stabilization of thephysiologic components of the primary survey, a meticu-lous neurological examination should be performed. Adetailed assessment should address the level of conscious-ness including documentation of the GCS, overall mentalstatus, cranial nerves, and motor/sensory function. Acomprehensive head-to-toe assessment should follow,assuming that the patient is physiologically stable, evalu-ating all other systems. Specific attention should be givento evaluation of the scalp. Oftentimes the penetrating

object is absent at the time of assessment. Penetratingwounds do not have usual sites or characteristic entrywounds and are often buried beneath blood-matted hair.Puncture wounds from objects such as ice picks are oftenminute and easily missed, causing a delay in diagnosis ofa craniocerebral injury.

Once physiologic stability has been ensured, labora-tory and radiological evaluations are vital to determiningthe extent of injury. Initial laboratory evaluation studiesshould include an arterial blood-gas analysis, completeblood cell count, chemistry panel, type and crossmatch,coagulation tests, and a drug screen including alcohollevel. Radiographic assessment may consist of a CTscan, skull series, angiography, and magnetic resonanceimaging. Computerized tomography scans can detect thepath and location of the embedded foreign body, boneand metal debris fragments, intracranial damage andhematomas, and mass effect. While CT scanning is con-sidered the gold standard for evaluation of intracranialinjury,5 it may be significantly blighted when a penetrat-ing metal object is embedded in the cranial vault.Because of the distortion, brain injury along the trajec-tory of the penetrating object may not initially be visual-ized. An immediate postoperative scan may bewarranted to look for missed contusion brain injury orhemorrhage.6 CT scans are also necessary to evaluateany changes in a patient’s mental status. Angiography isadvocated for initial evaluation of suspected cerebralvascular injuries caused by PETT and to evaluate post-operatively for the presence of a pseudoaneurysm. Whenordering a diagnostic cerebral angiogram looking forinitial vascular injury with an embedded metal object, itis important to specifically order a standard cerebralangiogram as opposed to a CT angiogram. In thesecases, the standard angiogram allows for much higher-resolution images because there is no artifact such aswould be seen with the CT angiogram. Magnetic reso-nance imaging is contraindicated in the presence of metal-lic fragments as the magnet may cause movement of theprojectile. A magnetic resonance imaging scan mayprovide more detailed information than a CT scan forpenetrating nonmetallic foreign objects.

Perioperative nursing considerationsThe most appropriate management for an embedded tran-scranial foreign object is to leave it in place until it can beremoved in a surgical suite under direct visualization.Minimal manipulation of the embedded object prior toremoval maximizes the preservation of cerebral functionby avoiding additional tissue damage and suddenexsanguination if the object is tamponading a majorvessel.7 Techniques employed to stabilize impaled objectsconsist of taping, wrapping with sterile towels, suturing inplace, covering with a cup, and possibly cutting the

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embedded object down in size to decrease the likelihoodof accidental manipulation or removal.8

Embedded object removal may cause many problems,as any movement during disimpaction may lead to fur-ther tissue or vessel damage with increased neurologicaldeficits. The individual may survive the initial injury, butremoval itself can lead to death. The impaled objectshould be removed along its trajectory. Depending on thelocation of the largest portion of the object, the foreignbody should be removed by either the antegrade or theretrograde route following the trajectory of entry.9 InPETT, the foremost purpose of surgery is to limit the pos-sible complications that can arise immediately after theremoval of the embedded object.10 If the patient is stable,it may be prudent to delay the surgical removal of theobject in order for the arrested bleeding secondary to thetamponade effect to become consolidated and the injuredvasculature can develop a firm clot.9 When deemedappropriate, the surgical procedure should be undertakento remove the embedded foreign body and to débridenecrotic tissue and clots followed by thorough hemosta-sis and dural closure.

Intensive care nursing considerationsMultiple concerns accompany victims of PETT in thepost–foreign body removal period. The primary concern isthe formation of a pseudoaneurysm. Rupture of traumaticintracranial aneurysm occurs within 3 weeks after theinitial injury and carries a 50% mortality rate.11 As manyof these lesions are not visible on initial arteriograms andhave a high likelihood of future development, routineangiography should be performed 7 to 14 days postinjuryon all patients.12 Another delayed complication is cerebralvasospasm. It characteristically appears within the first 2 weeks postinjury, principally days 5 through 11.11 If nottreated promptly, the end result of either vasospasm orpseudoaneurysm rupture is decreased cerebral perfusionpressure. A continued state of cerebral hypoperfusion willcause tissue hypoxia and cellular starvation with second-ary neuronal injury, which carries a very poor prognosis.

Another customary complication that follows PETT isinfection. Cerebrospinal fistulas, meningitis, and abscessare a few of the sources for infection. Bacterial contamina-tion occurs in the wound as a result of dirt, bone frag-ments, or other foreign matter entering along with theembedded foreign object. Organic materials, includingwood or bone, are more likely than inorganic projectiles,such as glass or metal, to fragment and become infectedbecause of their porous nature.13 Additional latent infec-tions may be composed of scalp infections, osteomyelitis,and cerebritis. Tetanus prophylaxis and antibiotics mayavert these infectious complications.14

Posttraumatic epilepsy is relatively commonplace afterPETT. Seizures are thought to arise secondary to direct

injury to the brain. Factors correlated with seizures con-sist of severity of injury, retained foreign debris, andhematoma formation.15,16 The neurological injury isthought to cause a hyperexcitability of neurons with aconsequential formation of an epileptic focus.Anticonvulsant prophylaxis administered in the immedi-ate postinjury period is believed to curb neuronal hyper-excitability and reestablish the seizure threshold.14,17,18

Specific nursing interventionsNursing interventions for patients with transcranialembedded foreign bodies may be categorized by the fol-lowing: (1) patient’s self-image, (2) family/loved-oneacceptance and perception, (3) physiologic manage-ment, (4) neurological function, and (5) multidiscipli-nary communication. The patient’s acceptance andadjustments to the traumatic injury are of great impor-tance to obtaining the maximum level of recovery.Acceptance of disfigurement and physical limitation areconsiderable obstacles to overcome. Nurses, by not onlycaring for but also caring about their patients, initiatethe healing process through their own acceptance oftheir patients’ appearance and physical condition. Thiscourse of action begins with the preparation of thepatient of what to expect. Compassionate honesty in allcommunications is vital to establishing a trusting bondin the nurse-patient relationship.

In cases involving victims of embedded transcranialobjects, one of the most important details is making surethe family sees the patient, providing his physical condi-tion permits, prior to the surgical procedure. Nurses withan expertise in dealing with this type of PETT recognizethe possibility of adverse events, including significantchanges in physical and neurological function and evendeath, occurring during the extrication procedure. Theimportance of the family seeing them just prior to theoperation cannot be overvalued. The patient/family needsto be made aware of the possible complications involvedduring the procedure to remove the impaled object andbe given the chance to discuss thoughts and feelings witheach other as well as with a healthcare professional toanswer questions. Nurses excel at this role because oftheir ability to see the big picture without losing sight ofthe smallest details.

To be an effective steward for a patient who has anembedded transcranial foreign body, the nurse must notonly possess the knowledge of appropriate nursing careof traumatic brain injury in general but also know thenuances of physiological monitoring and care associatedwith PETT, both nursing and medical. Nurses must bevigilant in reviewing all previous orders to ensure thatthey have been completed, in following up to be sure crit-ical time-sensitive results have been posted, and in view-ing current orders to be sure all the different disciplines

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are working cooperatively. This will ensure quality careas it provides the foundation for recognizing even subtlechanges in their patient’s physiological condition that canlead to secondary insult and further morbidity, if notaddressed in a timely manner.

Communicating with other team members in a clear,concise, and professional manner ensures an optimalchance for the best possible recovery. Reporting diagnos-tic results concerning physiological parameters unique topenetrating injuries, as well as, changes and responses to therapy is a continuum goal led by nursing.Understanding the divergence between blunt and PETTempowers nurses to bring different dimensions intopatient care.

■ CONCLUSIONEffective management of embedded transcranial foreignobjects necessitates an understanding of the mechanism ofinjury and associated neurological pathophysiology. Theindividual may survive the initial injury but later succumbto death as a result of manipulation and/or surgicalremoval of the impaled object or from delayed complica-tions such as the rupture of a pseudoaneurysm or develop-ment of an infectious process. Optimal outcomes forvictims of PETT can be provided through a multidiscipli-nary approach incorporating medical, surgical, and nurs-ing expertise. Nursing plays an integral role in ensuringthe best possible outcomes for patients who have sus-tained transcranial trauma. Nurses’ role as patient advo-cates ensures consistency throughout the multidisciplinarycontinuum of care.

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