Neck trauma

1. Neck trauma JasminFauteux August 25th, 2011

2. Goals -Briefly review the basics -Review difficult cases and develop a clinical approach -Discuss

3. What this will NOT BE • A review of our textbooks • A repeat of the last 2 presentations • A monologue

4. 22 yo female • Brought from jail after cutting her neck with butter knife • No suicidal intention • HIV, HCV, ASPD • No current bleeding • VS Normal

5. Platysma • Most superficial structure beneath skin • Covers anterior triangle and anteroinferior aspect of posterior triangle.

9. Roon and Christensen

10. Signs Neck trauma, Curr Probl Surg 2007;44:13-87. Demetriades D

11. Management +/- Flex endoscopy

12. 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

14. ?

15. Normal neurologic exam in penetrating trauma does NOT require c-spine precautions C-spine precautions

16. Airway - Soft

17. 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 +

18. Case • 52 yo, penetrating nail injury • Immediately removed nail • Bleeding controlled

19. Case • ABC’s are all unremarkable • No hard or soft signs • Exploration, platysma is midly violated

20. CTA: Trajectory visualized and not close to vital structures. Soft tissue injury only • Pt remains very well

21. If it violates the platysma, trauma wants to be involved

22. Case

23. Blunt neck trauma • 48 yoM, 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

24. Blunt trauma

25. 1 Neck soft tissue injury* Any c-spine fracture

26. 20-30% of pts have no identifiable criteriasand go unscreened until they become symptomatic

27. Screening modality?

29. 4 days later • Pt returns with acute onset aphasia,facial droop and hemiparesis…

30. Hang in there!

31. Hanging • Patient brought to rescus bay by EMS • What do you want to know?

32. Strangulation vs hangingJudicial vs n-judicialComplete vs incomplete

33. 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

34. 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

35. Up to 70% of hanging victims were found to be positive for EtOH or drugs

36. Over 90% of near-hanging victims will survive to be discharged Only 3,5% will have severe disability

37. Last case • 28 yo F, assaulted by husband • Was strangulated • Witness states LOC ~ 1 min

38. 79% of strangulation victims were assaulted by intimate partner

39. VS are normal and stable • On exam, only finding is finger marks and ecchymosis of neck • Who would CTA this patient?

40. Same patient, has minor hemoptysis and neck pain +++ on examination • Who would CTA this patient now?

41. 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

42. Thanks • Marc Francis • Mike Hodsman • RohanLall • Chad Ball • Monica Hoy • Lee Graham