higher index of suspicion when evaluating an injured adult cyclist for these injuries.

Preventing handlebar injuries is quite difficult. Retract- able handlebars that would absorb energy on collision are under investigation [8]. Prevention is probably best empha- sized by promotion of safe bicycling habits. Fitting a person for a bicycle appropriately is extremely important, specif- ically sizing appropriately for the person’s weight, age, and skill level. Good bicycle maintenance is also an important factor in prevention of all types of bicycle-related injuries.

Jeffrey H. Bohmer MD Arthur F. Proust MD

Department of Emergency Medicine Delnor Community Hospital Geneva, IL 60134, USA

doi:10.1016/j.ajem.2005.12.022

References

1. Winston FK, Weiss HB, Nance ML, et al. Estimates of the incidence and costs associated with handlebar-related injuries in children. Arch Pediatr Adolesc Med 2002;156:922 - 8.
2. Winston FK, Shaw KN, Kreshak AA, et al. Hidden spears: handlebars as injury hazards to children. Pediatrics 1998;102:596 - 601.
3. Guerro MA, Lin PH, Bush RL, et al. Splenic and pancreatic infarction due to motorcycle handlebar injury. J Trauma 2005;58:1304.
4. Tracy TF, Silen ML, Graham MA. Delayed rupture of the abdominal aorta in a child after a suspected handlebar injury. J Trauma 1998;40:119 - 20.
5. Munshi IA, Khachi GK. Bicycle handlebar injury. J Emerg Med 2003;24:215 - 6.
6. Erez I, Lazar L, Gutermacher M, et al. Abdominal injuries caused by bicycle handlebars. Eur J Surg 2001;167:331 - 3.
7. Nolan BW, Gabram SGA, Schwartz RJ, et al. Mesenteric injury from blunt abdominal trauma. Am Surg 1995;61:501 - 6.
8. Arbogast KB, Choen J, Otoya L, et al. Protecting the child’s abdomen: a retractable bicycle handlebar. Accid Anal Prev 2001;33:753 - 7.

An unusual form of self-mutilation: tongue amputation with local anesthesia

Self-mutilation is generally defined as the behaviors damaging body tissues seriously without aiming death consciously [1-4]. Self-mutilation is expressed as self-aid action that is fast, providing a temporary solution to be rid of depersonalization, guilt, the sensation of being refused, hallucination, being busy with sexual subjects, and complex feelings [5]. However, in some cases, self-mutilation, especially the behavior of bcutting,Q provides one to return to reality or to be saved from anxiety [6,7]. Besides being able to be seen together with various psychiatric disorders (schizophrenia, depression, personality disorders, and men- tal retardation, etc), it can also be seen in growth disorders and other syndromes [8].

The self-mutilating patient is an unusual psychiatric presentation in the ED. The three most commonly reported

types of self-injurious behavior are self-cutting of the skin, ocular self-mutilation, and genital self-mutilation [1]. Among these cases, repeating self-mutilation cases of various organs are encountered, but we could not find a case about tongue amputation accompanied with local anesthesia related with repeating schizophrenic auto-castration and self-mutilation, and we discussed the case.

The patient, who is 27, single, unemployed, and living in a district, was brought to the Medical Faculty of Pamukkale University by his family. The rise of sounds he heard; being in doubt about his near environment, this patient who has been observed with the diagnosis of schizophrenia for seven years has begun to experience nervous attitudes. The voice he has been hearing has been telling him that he must cut his tongue. Then, the patient cut his tongue and was brought to the emergency service by his relatives. He had also cut his testicles and penis complying with the voice he had heard beforehand. The first vital diagnosis of the patient was evaluated as normal. According to the patient, he expressed that he cut one-third part of his tongue’s tip about 2 hours ago. Before cutting, so as not to feel the pain, he said that he bought the medicine named Jetokain (Lidocaine HCI 20 mg, Epinephrine 0, 125 mg/mL) ampule from a chemist and then he injected a part of the 18-ampule Jetokain to the bottom and on the top of his tongue. He poured some of the medicine and cut his tongue. The patient, living in the country without any health official, said that he had learned of the local anesthesia he made by observing a dentist from whom he received tooth treatment. To prevent the piece of his tongue that he cut from being sewn on again, the patient said that he cut that piece into smaller pieces with a pair of scissors. In the first physical examination of the patient who was taken to the nearest second-step health clinic and sent to our emergency service after the first interference, a straight cut on the front part of the tongue with amputation of one- third distal part of the tongue (amputated part was separated into very small parts) without active bleeding of the cut was determined (Fig. 1A). A tetanus toxoid was applied to the patient, analgesia was provided, and antibiotherapy was started. After otolaryngology and head and neck surgery consultation, urgent reconstructive surgery interference was not considered because the amputated piece was separated into too little pieces, making reconstruction inapplicable. The patient, whose other system examinations were determined as normal, was learned to take medical treatment with the diagnosis of chronic schizophrenia for approximately 7 years, and he was taking Fluphenazine decanoate retard 25 mg every 15 days intramuscular, Biperidene HCI 6 mg/day, and Risperidone 3 mg/day.

The patient was consulted and evaluated by psychiatry in the emergency service. In the psychological examination of the patient, his conscious was open; he was orientative, cooperative, quiet, calm, and introverted; and person, time, and place orientation was good. He looked his age, seemed plump, self-care was bad. He had a difficulty because of the tongue cut. According to the information obtained from his

Fig. 1 A-B: The cross section of 1/3 of tongue, before and after the treatment.

relatives, lack of desire existed emotionally, there were visual and Auditory hallucinations in his story and percep- tion. He did not have insight and had bad judgment and evaluation of fact. At the end of the psychological examination, according to the criteria of DSM IV, paranoid schizophrenia was diagnosed. The intelligence of the patient was evaluated as normal in an applied neuropsychological test (according to WAIS-R test); difficulty on the control of compulsion was determined according to thematic apper- ception test (TAT). Constriction of attention,difficulty in learning, and decrease in the skill of abstracting were determined. There were self-mutilation attitudes. There were sudden anger attacks and akathisia. Physically, sleep was irregular and appetite was increased. It was decided that the patient was required to be put and treated in a closed-refuge psychiatry service on account of the high risk of repeated self-mutilation (the patient was saying that he would cut his leg). The patient holds in the psychiatry service for 10 days was started as a treatment of Quetiapine fumarate 900 mg/day because of chronic psychosis. Inasmuch as the maladjustment to the treatment was taken into consid- eration, Fluphenazine decanoate retard was applied. Sys- temic and local antibiotherapy and analgesic treatment were applied to the patient having an ache in his tongue during that period. He was discharged after 10 days with an

improvement (Fig. 1B). After the two months of following of the patient, there was a decrease in auditory hallucina- tions. Thoughts about cutting his leg were continuing although it decreased. After 2 months of following, the patient was seen to take his treatment regularly and there were no self-mutilative attempts.

In the biography of the patient it was learned that he was graduated from a secondary school, living in a village being unemployed. Although there was no complaint up to when he reached 15 years of age, schizoid attitudes, escaping from home, hearing voices, something appearing before his eyes, and thoughts of his relatives doing harm to him started. He said that he stayed in psychiatry clinics of various hospitals for three times before. It was learned that the patient did not take regular treatment, and he tried new surgical methods on cats on different times. After going to the army in his 20s, he was sent a report after 3 months saying he cannot do his military service.

According to information received from the family of the patient, it was learned that the patient had formed a 2nd- stage burn on his skin five years ago by collecting some lime powder in his pocket and pouring water on it (Fig. 2). According to the received information from his family, approximately 2 years ago, the patient had cut his genital organs completely, specifically his testicles and penis, by making anesthesia and then separating the pieces he cut off into smaller pieces to prevent them from being sewn in place again; in the same way he did with cutting his tongue (Fig. 3A-B).

Self-mutilation or self-injury expresses a form of behavioral disorder seen in various psychiatric disorders such as personality disorders that can be understood more difficultly or as schizophrenia that can be understood more easily [9]. Self-mutilation was seen as a symptom of under- lying stress or anxiety. It is proposed for this behav- ioral disorder that it decreases one’s inside tension and confusion [10].

Taiminen et al [2] classified self-mutilation in two groups according to its intensity. Major self-mutilation is, in these

Fig. 2 The scar tissue developed depending on the chemical burn by lime powder in the thigh proximal-lateral part.

Fig. 3 A-B: The total genital organ cross section of the penis and testicles.

situations, removing his eye and amputation of extremities or genital organs, and mostly these are seen in psychotic disorders or heavy sexual identity disorders. As for minor self-mutilation, it includes some behaviors such as cutting and burning the skin, inserting pins, extraction of blood, biting himself, tearing out hair, and breaking bones. Favazza

[5] considered the self-mutilative attitudes in three groups: majorly injuring himself, for example, making a permanent damage to his body such as carving his eye, castration, stereotypically injuring himself; attitudes that occur in Tourette syndrome and in mental retardation, for example, recurrence of hitting his head, biting himself, injuring himself superficially or with moderate intensity; and attitudes such as making cuts on the skin, burning himself, and tearing his hair.

In our case, we can see as revealed in literature, retroactive recurrence of self-mutilation behaviors known as minor (making burned-scar tissue in the skin with lime powder) and major (total genital self-mutilation). However, different from previously known self-mutilation behaviors, we can see a self-mutilation event such as tongue cut in our case. According to our literature study, although self- mutilation behaviors to face, mouth, and lips, even rarely, are informed (especially encephalitis, coma, cerebral palsy, autism, mental retardation, seizures, as well as familial

dysautonomia, Lesch-Nyhan syndrome, Tourette syndrome, and the Cornelia de Lange syndrome) [9,11]; self-mutilation with tongue cut is not a rather frequent case in these kinds of psychotic patients previously.

Self-mutilation is described as painful, destructive behaviors to harm the body tissues without aiming suicide evidently [4]. During the self-mutilative behaviors depen- dent upon personality disorders, feeling pain is decreasing in a noticeable manner or completely disappears [10]. Pain is not perceived by the patient, even if he feels better after the cutting process. However, although psychotic patients such as schizophrenic patients show more tolerance to pain than normal people, the sense of pain is known not to have completely disappeared [12]. Another unusual behavior seen in our case that is different from the previous cases is his application of local anesthesia to himself with Jetokain, which he saw from a dentist because of the painful action. Although the patient is not a health service employee, we see that he learned and applied a kind of premedication such as this local anesthesia before the cutting process in the genital self-mutilation of two years ago.

This unusual, strange behavior of injuring himself indicates the scarcity of insight and severity of Psychotic symptoms. In the psychiatric tests after a 10-day treatment of the patient in the psychiatry service, we saw the results indicating the severity of psychosis of the patient. As it is in our case, saying that he would cut his legs during the examination, in these kinds of patients, generally, prognosis is not good. At the end of the 2-month following, by the treatment of depot antipsychotic and oral atypical antipsy- chotic, the complaining of the patients decreased; with decreasing voices telling him to cut his leg, and the insight of the patient about his illness increased; he was seen as saying these voices were because of his illness. The low quality of the social support system, the difficulties for this patient to take a regular treatment brought up the difficulty of the future treatment of this patient. However, a careful and step-by-step approach of emergency service is neces- sary. The evaluation and treatment of these patients needing a multidisciplinary approach are generally difficult. A complete physical examination should be done to prevent possible self-mutilation in other parts of his body. Behav- iors of injuring himself come in all diagnostic classifica- tions; any of the diagnosis is not pathognomonic. Nevertheless, the more unusual the self-mutilation done, the higher possibility of the patient to be psychotic [9]. It appears that clinicians should be more careful about psychotic patients, especially those having a self-mutilation story before. Especially with the existence of auditory hallucinations, ordering self-mutilation is a diagnosis needing to be given attention.

Potentially, in the evaluation of a self-mutilative patient during his application to emergency service, after providing his stabilization, his mental situation (usage of alcohol or drugs, existence of hallucinations, etc) during the evaluation of behavior should be appraised in point of psychiatry and

other related department’s consultations; the underlying diagnosis of self-mutilation should be found and necessary assistance for the patient to benefit from psychiatric treatment service should be provided. Yet, medical or surgical treatment and stabilization are urgent primary approaches in self-mutilative patients, with regard to recurrent morbidity and potential mortality, psychiatric/ psychosocial following should not be neglected; other possible self-mutilations should be prevented.

Bulent Erdur MD Ibrahim Turkcuer MD

Department of Emergency Medicine Medical Faculty, Pamukkale University Kinikli 20070, Denizli, Turkey

E-mail address: [email protected]

Hasan Herken MD

Department of Psychiatry Medical Faculty, Pamukkale University Kinikli 20070, Denizli, Turkey

doi:10.1016/j.ajem.2005.12.020

References

1. Feldman MD. The challenge of self-mutilation: a review. Compr Psychiatry 1988;29:252 - 69.
2. Taiminen TJ, Kallio SK, Nokso KH, et al. Contagion of deliberate self-harm among adolescent inpatients. J Am Acad Child Adolesc Psychiatry 1998;37:211 - 7.
3. Dallam SJ. The identification and management of self-mutilating patients in primary care. Nurse Pract 1997;22:159 - 65.
4. Bharath S, Neupane M, Chatterjee S. Terminator: an unusual form of self-mutilation. Psychopathology 1999;32:184 - 6.
5. Favazza AR. The coming age of self-mutilation. J Nerv Ment Dis 1998;186:259 - 68.
6. Goldney RD, Lester D. Ethology and self-injury. Br J Psychiatry 1997;170:192 - 3.
7. Welsh JR. In whose dbest interestsT? J Adv Nurs 1998;27:45 - 51.
8. Aksu G, Sayar MK, Ak I. Genital self mutilasyon veya Otokastrasyon. Y’ bni Sina Tip Dergisi 2002;7:115 - 7.
9. Birrer RB, Robinson T, Rao S, et al. Self-mutilation: three cases and a review of the literature. J Emerg Med 1993;11:27 - 31.
10. Cavanaugh RM. Self-mutilation as a manifestation of sexual abuse in adolescent girls. J Pediatr Adolesc Gynecol 2002;15:97 - 100.
11. Pantanowitz L, Berk M. Auto-amputation of the tongue associated with flupenthixol induced extrapyramidal symptoms. Int Clin Psy- chopharmacol 1999;14(2):129 - 31.
12. Murthy BVS, Narayan B, Nayagam S. Reduced perception of pain in schizophrenia: its relevance to the clinical diagnosis of compartment syndrome. Injury 2004;35:1192 - 3.

Asymptomatic posttraumatic pneumocephalus

A 22-year-old man presented to the Royal Perth Hospital ED after an alleged assault. Clinical examination showed no neurologic compromise, normal reflexes, and a Glasgow Coma Scale score of 15. Vital signs and physical examina- tion were unremarkable. The patient’s medical history

revealed no disorder and no drug or alcohol use. Routine laboratory test findings were normal. A computed tomog- raphy (CT) scan revealed a longitudinal fracture through the right petrous Temporal bone. Moreover, a significant amount of intracranial gas, distributed in a parafalcine manner, was present in the anterior aspect of both frontal lobes, the right temporal lobe, and the right cerebellum (Figs. 1 and 2). No Battle’s sign or Raccoon eyes was noted. The patient subsequently developed cerebral spinal fluid otorrhea. No neurosurgical intervention was deemed necessary, and the patient’s base of Skull fracture was treated conservatively. He was discharged from the hospital with scheduled neurologic follow-up.

The incidence of pneumocephalus is reported to be between 0.5% and 1.0% of patients with a traumatic brain injury [1]. The incidence is significantly higher in patients with basilar Skull fractures, with one study noting a 10-fold increase [2]. Studies measuring the incidence of pneumo- cephalus using CT scans report higher Incidence rates because of the enhanced sensitivity of the imaging [3]. Furthermore, the earlier after an injury that patients are imaged, regardless of technique, the more likely pneumo- cephalus is detected.

Acute traumatic pneumocephalus is diagnostic of a basilar skull fracture, whereas late pneumocephalus, which appears a few days postinjury, is suggestive of a cerebral spinal fluid fistula. Posttraumatic pneumocephalus occurs when there is a continuous, albeit sometimes very slow, collection of intracranial air. This type of pneumocephalus may produce mass effect and, as a consequence, neurologic signs/symptoms and a deterioration in functional status. Typical symptoms include increased intracranial pressure (eg, vomiting, nausea, and headache) and impaired con- sciousness. Other neurologic signs, including seizures, visual field defects, and behavioral changes, have been reported [4]. Acute complications include venous air

Fig. 1 Initial axial Brain CT scan showing a bilateral frontal pneumocephalus.