Case Reports

97
[3] Barss P. Wound necrosis caused by the venom of stingrays.
Pathological findings and surgical management. Med J Aust 1984;
141:854 - 5.
[4] Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from
marine creatures. Am Fam Physician 2004;69(4):885 - 90.
[5] Russell FE, Panos TC, Kang LW, et al. Studies on the mechanism of
death from stingray venom: a report of two fatal cases. Am J Med Sci
1958;235:566 - 83.
[6] Jain AL, Robertson GJ, Rudis MI. Surgical issues in the poisoned
patient. Emerg Med Clin North Am 2003;21:1117 - 44.

An unusual primary blast injuryB

Traumatic brain injury due to primary blast injury
Fig. 4 This spine is from a southern stingray (Dasyatis
americana) and measures 22 cm (photo courtesy of Dr Carl A.
Luer and Mote Marine Laboratory).

infection [4]. Life-threatening and fatal injuries are rare but

have occurred after abdominal or thoracic penetration,
injury to the femoral artery, and tetanus [2,5].
Patients with significant blood loss should be treated
with aggressive fluid resuscitation and transfusion if
necessary. Wounds require irrigation, exploration, and
debridement. Caution should be used when removing an
embedded spine because this can cause further release of
venom [6]. The wound should be allowed to heal through
delayed primary closure [1]. Patients should be placed on a
prophylactic antibiotic that covers Staphylococcus, Streptococcus, Vibrio vulnificus, and Mycobacterium marinum[4].
A tetanus vaccine or tetanus toxoid should be given, if
indicated [2]. Patients with wounds that may have penetrated the thoracic or abdominal cavities should have further
assessment to rule out other associated life-threatening
injury [2]. It is recommended that patients be observed for
at least 3 hours for systemic adverse effects [1]. The patient
should be advised to return in 48 hours for wound
reevaluation and to return sooner for signs and symptoms
of infection.
Charlotte Derr MD
Barbara J. OConnor RN, MBA
Sandra L. MacLeod MD, MPH
Sarasota County Fire Department
Emergency Services, Sarasota
FL 34236, USA
doi:10.1016/j.ajem.2006.04.016

References
[1] Auerbach PS. Envenomation by aquatic invertebrates. In: Auerbach PS,
editor. Wilderness medicine. 4th ed. St. Louis (Mo)7 Mosby Inc; 2001.
p. 1488 - 92.
[2] Fenner PJ, Williamson JA, Skinner RA. Fatal and non-fatal stingray
envenomation. Med J Aust 1989;151:621 - 5.

The reports on primary blast injuries focus on damage in

gas-containing organ systems; however, the likelihood of
blast-induced neurotrauma is often overlooked or related to
secondary or tertiary injury cause [1]. We report a case of
traumatic brain injury due to primary blast injury caused by
work-related accident.
A 36-year-old male worker with blast injury due to steam
boil explosion was admitted to the ED. On arrival, the
patients vital signs were normal. The Glasgow Coma Scale
(GCS) score was recorded as 15/15. There were no blunt or
penetrating wound sign on head and neck examinations
other than left side tympanic membrane rupture. Seconddegree burns (about 12%) were found on the left upper arm.
Mental status was depressed when chest x-ray was
performed. The patient was intubated when his GCS
declined to 8/15 within several minutes and his pupils
became anisocoric. Computed tomography of the head
displayed mild cerebral edema, minimally depressed linear
petrose bone fracture, left temporoparietal epidural hemorrhage, and diffuse subarachnoid hemorrhage (Fig. 1). The
patient had surgery as quickly as possible. On the following
days, he was observed in the intensive care unit and died
on postoperative 25th day.
Explosions can result in unique injury patterns to the
central nervous system (CNS) [2]. Neurological impairment
due to blast injury was initially attributed to air emboli in the
cerebral circulation. In addition, studies on animals suggest
that the overpressure wave is transferred to the central
nervous system, causing diffuse axonal injury. Higher levels
of blast overpressure can cause skull fractures or coupcounter-coup injuries [3- 5].
There have been several theories related to the mechanism of brain damage after primary blast exposure. First,
shock waves are transmitted to the brain via viscera,
muscles, bones, blood vessels, and cerebrospinal fluid
[6,7]. Second, the blast may create a higher pressure in

B
Authors contributions: Serkan YVVlmaz did patients care and
management and conceived the paper. Manuscript was written by Serkan
YVVlmaz and Murat Pekdemir. All authors drafted the manuscript and
contributed substantially to its revision.

98

Case Reports

Fig. 1 Computed tomography image showed mild cerebral edema, minimally depressed linear petrose bone fracture, left temporoparietal
epidural hemorrhage, and diffuse subarachnoid hemorrhage.

the body except in the cranium; therefore, the blood from

the largest vessels may be squeezed into this low-pressure
area [7]. When these reach the CNS, it is likely that they
generate high-pressure differentials, resulting in rupture of
the blood vessels in the meninges and brain tissue.
This case appears to have been caused by primary blast
injury. The patients head and neck examinations were
unimpressive, and he had no neurological deficit on arrival,
with a GCS recorded as 15/15. With the rising risk of
terrorist bombings in many parts of the world, emergency
physicians need to consider initially occult traumatic brain
injury due to blast wave.
Serkan YVlmaz MD
Murat Pekdemir MD
Department of Emergency Medicine
School of Medicine, Kocaeli University
41380 Kocaeli, Turkey
E-mail addresses: emdsercy@yahoo.com
mpekdemir@yahoo.com
doi:10.1016/j.ajem.2006.04.014

References
[1] DePalma RG, Burris DG, Champion HR, et al. Blast injuries. N Engl J
Med 2005;352:1335 - 45.
[2] Lavonas E, Pernardt A. Blast injuries. [Emedicine Web site]. January
17, 2006. Available at: http://www.emedicine.com/emerg/topic63.htm
[Accessed March 6, 2006].
[3] Singer P, Cohen J, Stein M. Conventional terrorism and critical care.
Crit Care Med 2005;33:61 - 5.
[4] Mayorga M. The pathology of blast overpressure injury. Toxicology
1997;121:17 - 28.
[5] Sutphen SK. Blast injuries: a review. [Medscape Web site]. November
9, 2005. Available at: http://www.medscape.com/viewprogram/4714
[Accessed March 10, 2006].
[6] Cernak I, Wang Z, Jiang J, et al. Ultrastructural and functional
characteristics of blast injury-induced neurotrauma. J Trauma 2001;50:
695 - 706.
[7] Siri KK, Egil O. Blast induced neurotrauma in whales. Neurosci Res
2003;46:377 - 86

Gastric outlet obstruction in an infant: lactobezoar

A nearly 4-month-old infant, former product of an
uncomplicated term, twin gestation, presented to the ED