Transcript Neck trauma
Neck trauma Jasmin Fauteux August 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 Signs Hard 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 wound RR = 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 ? Normal neurologic exam in penetrating trauma does NOT require c-spine precautions 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 Neck soft tissue injury* Any c-spine fracture 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 hanging Judicial vs n-judicial Complete vs incomplete ABC’s • • • • • A B C D E LMA in place, bagged, good chest rise GAEB, Sa02 = 98% NSR, BP = 80/40 Pupils fixed at 2mm, GCS = 3 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