neck trauma jasmin fauteux august 25 th, 2011. goals -briefly review the basics -review difficult...
TRANSCRIPT
![Page 1: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/1.jpg)
Neck traumaJasmin FauteuxAugust 25th, 2011
![Page 2: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/2.jpg)
Goals
-Briefly review the basics
-Review difficult cases and develop a clinical approach
-Discuss
![Page 3: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/3.jpg)
What this will NOT BE
- A review of our textbooks
- A repeat of the last 2 presentations
- A monologue
![Page 4: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/4.jpg)
22 yo female
• Brought from jail after cutting her neck with butter knife
• No suicidal intention• HIV, HCV, ASPD• No current bleeding• VS Normal
![Page 5: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/5.jpg)
Platysma• Most superficial structure beneath skin• Covers anterior triangle and anteroinferior
aspect of posterior triangle.
![Page 6: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/6.jpg)
![Page 7: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/7.jpg)
![Page 8: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/8.jpg)
![Page 9: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/9.jpg)
Roon and Christensen
![Page 10: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/10.jpg)
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
![Page 11: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/11.jpg)
Management
+/- Flex endoscopy
![Page 12: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/12.jpg)
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
![Page 13: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/13.jpg)
![Page 14: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/14.jpg)
?
![Page 15: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/15.jpg)
C-spine precautionsNormal neurologic exam in penetrating trauma does NOT require c-spine precautions
![Page 16: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/16.jpg)
Airway - Soft
![Page 17: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/17.jpg)
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 +
![Page 18: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/18.jpg)
Case
• 52 yo, penetrating nail injury
• Immediately removed nail
• Bleeding controlled
![Page 19: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/19.jpg)
Case
- ABC’s are all unremarkable- No hard or soft signs- Exploration, platysma is midly violated
![Page 20: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/20.jpg)
- CTA: Trajectory visualized and not close to vital structures. Soft tissue injury only
- Pt remains very well
![Page 21: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/21.jpg)
If it violates the platysma, trauma wants to be involved
![Page 22: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/22.jpg)
Case
![Page 23: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/23.jpg)
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
![Page 24: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/24.jpg)
Blunt trauma
![Page 25: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/25.jpg)
1
Any c-spine fracture
Neck soft tissue injury*
![Page 26: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/26.jpg)
20-30% of pts have no identifiable criterias and go unscreened until they become symptomatic
![Page 27: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/27.jpg)
Screening modality?
![Page 28: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/28.jpg)
![Page 29: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/29.jpg)
4 days later
• Pt returns with acute onset aphasia, facial droop and hemiparesis…
![Page 30: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/30.jpg)
Hang in there!
![Page 31: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/31.jpg)
Hanging• Patient brought to rescus bay by EMS
• What do you want to know?
![Page 32: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/32.jpg)
Strangulation vs hangingJudicial vs n-judicial
Complete vs incomplete
![Page 33: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/33.jpg)
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
![Page 34: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/34.jpg)
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
![Page 35: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/35.jpg)
Up to 70% of hanging victims
were found to be positive for EtOH
or drugs
![Page 36: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/36.jpg)
Over 90% of near-hanging victims will survive to be discharged
Only 3,5% will have severe disability
![Page 37: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/37.jpg)
Last case- 28 yo F, assaulted by husband
- Was strangulated
- Witness states LOC ~ 1 min
![Page 38: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/38.jpg)
79% of strangulation victims were assaulted by intimate
partner
![Page 39: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/39.jpg)
• VS are normal and stable
• On exam, only finding is finger marks and ecchymosis of neck
• Who would CTA this patient?
![Page 40: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/40.jpg)
• Same patient, has minor hemoptysis and neck pain +++ on examination
• Who would CTA this patient now?
![Page 41: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/41.jpg)
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
![Page 42: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/42.jpg)
Thanks
• Marc Francis• Mike Hodsman• Rohan Lall• Chad Ball• Monica Hoy• Lee Graham
![Page 43: Neck trauma Jasmin Fauteux August 25 th, 2011. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss](https://reader031.vdocuments.net/reader031/viewer/2022032517/56649c8a5503460f949441e2/html5/thumbnails/43.jpg)