Neck trauma

Report
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
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•
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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
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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
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•
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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
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Marc Francis
Mike Hodsman
Rohan Lall
Chad Ball
Monica Hoy
Lee Graham

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