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