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Special Feature
Apr 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: US Army Institute of Surgical Research, Fort Sam Houston, Texas (Dr Renz); Departments of Surgery (Drs Renz and Ecklund) and Neurology (Dr Ling), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Altru Health System, Fargo, North Dakota (Dr Mork); and Inova Fairfax Hospital, Falls Church, and Department of Neurosurgery, Virginia Commonwealth University, Richmond (Dr Ecklund).

Arch Surg. 2012;147(4):391-392. doi:10.1001/archsurg.2011.872a

A 41-year-old man visited the emergency department because of acute onset of a headache as he was walking home after a local soccer match. The patient reported hearing what sounded like gunfire in the distance, but nothing to suggest danger to him or anyone else in the vicinity. While walking, he felt something hit the top of his head. Reaching up, he felt a small solid object barely protruding from his scalp for which he now sought medical care. He denied any change in consciousness, change in vision, nausea, weakness, or any other symptoms; he denied the use of any medications or alcohol. Physical examination revealed a healthy-appearing man in no acute distress with normal vital signs and no neurological deficit. Examination of his scalp near the area of reported pain revealed a small, circular, metallic object beneath his hair, flush with his scalp and surrounded by traces of dried blood (Figure 1).

Figure 1. Foreign body imbedded in the scalp.

Figure 1. Foreign body imbedded in the scalp.

What Is the Most Appropriate Initial Management?

A.  Clean the wound with chlorhexidine gluconate and remove the foreign body under local anesthetic in the emergency department

B.  Administer hypertonic saline to minimize the possible effects of intracerebral edema

C.  Send serum for coagulation studies and obtain computed tomographic imaging of the brain

D.  Without delaying for computed tomography, move the patient to the operating room for emergent removal of the foreign body