Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult...
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Transcript of Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult...
Neck traumaJasmin FauteuxAugust 25th, 2011
Goals
-Briefly review the basics
-Review difficult cases and develop a clinical approach
-Discuss
What this will NOT BE
- A review of our textbooks
- A repeat of the last 2 presentations
- A monologue
22 yo female
• Brought from jail after cutting her neck with butter knife
• No suicidal intention• HIV, HCV, ASPD• No current bleeding• VS Normal
Platysma• Most superficial structure beneath skin• Covers anterior triangle and anteroinferior
aspect of posterior triangle.
Roon and Christensen
SignsHard Soft
Respiratory distress LT Subcutaneous emphysema LT/PE
Air bubbling neck wound LT Hoarseness LT
Major hemoptysis LT Minor hemoptysis LT
Severe active bleeding Vasc Minor bleeding Vasc
Large expanding hematoma Vasc Small to moderate hematoma Vasc
Diminished/absent pulse Vasc Proximity wounds Vasc
Unexplained hypotension Vasc Hypotension responding to fluids Vasc
Bruit Vasc Painful swallowing PE
Hematemesis PE
Neck trauma, Curr Probl Surg 2007;44:13-87. Demetriades D
Management
+/- Flex endoscopy
Airway - Hard
• 46yo male, at church• Shot in neck• A Hoarse voice
Air bubbling thru woundRR = 36 SaO2 = 89% 100NRB
• B Decreased AE x 2• C HR = 86 BP = 116/76• D GCS =15 ,PERL 3mm, MA4L• E C-spine collar in place
?
C-spine precautionsNormal neurologic exam in penetrating trauma does NOT require c-spine precautions
Airway - Soft
Clothesline accident
• 14yo M• 60km/hr, 30 min ago• A Minor hemoptysis, mild voice
hoarseness• B Sao2 = 99% on 8L NP, GAEB, WOB is N• C No other bleeding, HR = 84, BP =128/84• Rest of exam is unremarkable• C-spine precautions +
Case
• 52 yo, penetrating nail injury
• Immediately removed nail
• Bleeding controlled
Case
- ABC’s are all unremarkable- No hard or soft signs- Exploration, platysma is midly violated
- CTA: Trajectory visualized and not close to vital structures. Soft tissue injury only
- Pt remains very well
If it violates the platysma, trauma wants to be involved
Case
Blunt neck trauma
• 48 yo M, restrained, driver vs moose• A Talking full sentences, trachea central• B GAEB, SaO2 = 99% RA• C Good pulses bilat, BP = 124/76, HR = 88• D GCS = 15, PERL at 3mm, MA4L• E C-spine collar
Neck abrasion
Blunt trauma
1
Any c-spine fracture
Neck soft tissue injury*
20-30% of pts have no identifiable criterias and go unscreened until they become symptomatic
Screening modality?
4 days later
• Pt returns with acute onset aphasia, facial droop and hemiparesis…
Hang in there!
Hanging• Patient brought to rescus bay by EMS
• What do you want to know?
Strangulation vs hangingJudicial vs n-judicial
Complete vs incomplete
ABC’s
• A LMA in place, bagged, good chest rise• B GAEB, Sa02 = 98%• C NSR, BP = 80/40• D Pupils fixed at 2mm, GCS = 3• E C-spine collar in place
Tardieu’s spots
On physical exam
• Ligature marks• Tardieu’s spots• Laryngo-tracheal symptoms
• Hoarseness, stridor, • Focal tenderness or crepitation• Dysphagia
• CNS depression from GCS 3 to nil• Respiratory compromise from severe to nil
Up to 70% of hanging victims
were found to be positive for EtOH
or drugs
Over 90% of near-hanging victims will survive to be discharged
Only 3,5% will have severe disability
Last case- 28 yo F, assaulted by husband
- Was strangulated
- Witness states LOC ~ 1 min
79% of strangulation victims were assaulted by intimate
partner
• VS are normal and stable
• On exam, only finding is finger marks and ecchymosis of neck
• Who would CTA this patient?
• Same patient, has minor hemoptysis and neck pain +++ on examination
• Who would CTA this patient now?
In summary• Platysma violated = trauma consult
• Treat every neck trauma as a difficult airway & think ahead
• Know your hard & soft signs and investigate accordingly
• C-spine in penetrating if GSW + low GCS/neuro signs
• In blunt, think about BCVI
• In hangings: Resuscitate first, Prognosticate later*
*P. M. Hodsman
Thanks
• Marc Francis• Mike Hodsman• Rohan Lall• Chad Ball• Monica Hoy• Lee Graham