263. Penetrating Trauma to the Extremities

General

In 1950, vascular involvement of penetrating extremity injuries usually lead to 50% chance of amputation. Now, usually < 5%.

Vascular Injury

First assessment on extremity injury is looking for arterial injury. Check color, temp, cap refill (cap refill not very sensitive though). ABIs: Doppler BP to all 4 extremities. Best upper extremity BP used. Equation is affected lower extremity BP / best upper extremity BP. Normal ABI should be > 1. If lower, need to consider arterial involvement. Also can put BP cuff proximal to injury and check doppler distal to injury.

Hard signs: 90% chance of arterial injury: absent/diminished pulses, obvious arterial bleeding, large expanding or pulsatile hematoma, audible bruit, palpable thrill, distal ischemia.

Soft signs: 35% risk of arterial injury: small, stable hematoma, unexplained hypotension, history of hemorrhage, proximity of injury to major vascular structures.

Xray joints above and below suspected injury. CTA is noninvasive, test of choice for assessing vascular involvement, though angiography is ‘gold standard.’ CTA is 98-100% specific, 90-95% sensitive. Doppler is good, though hard to assess for intimal flap or pseudoaneurysm.

50% of peripheral nerve injuries have vascular component as well. Major neurvascular bundles: axillary artery / brachial plexus, brachial artery / median nerve, radial artery / mean and radial nerve, ulnar artery / ulnar nerve, femoral artery / femoral nerve, popliteal artery / tibial nerve.

Popliteal artery: consider with complete ligamentous disruption of knee – likely has reduced knee dislocation. CTA usually recommended along with ABIs.

Subclavian artery: physical exam and CXR will show hemothorax, pneumothorax, apical pleural cap or wide mediastinum. CTA for better accuracy.

Arterial injuries need to be repaired in 6 hours. Endovascular treatment with stents is becoming more mainstream.

Complications: monitor for signs of compartment syndrome after reperfused proximal vascular injury due to edema, free radicals, etc. Delayed thrombosis can occur months to years after previous stricture, intimal flap injury from previous fracture.

Wound Management

Bleeding: do not clamp or ligate. Direct pressure is best. If unable to control with direct sustained pressure, tourniquets can be used, though only safe if used for less than 6 hours. Wound management should be irrigation. Large mount of 500-1000mL of saline or water at least. Antiseptic wash is not recommended and shown to have any other benefit. High pressure irrigation recommend – can use 60mL syringe with 18g needle.

Organic material more prone to infection compared to inert material like bullets/metal.

Joint involvement usually requires ortho consult for wash-out with stab/GSW. Bone fractures from penetrating injuries should be treated as open fractures.

Patients with penetrating injury with no arterial injury, no bony or nerve injury, minimal soft tissue defect and no signs of compartment can be discharge with close followup instructions. Knife/GSW soft tissue wounds are low risk for infection and prophylactic abx not recommended.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 263: Penetrating Trauma to the Extremities

Rosens, Chapter 41: Peripheral Vascular Injuries

263. Penetrating Trauma to the Extremities

262. Genitourinary Trauma

Kidney Injuries

80% of kidney injuries have associated trauma.

No direct relationship between presence or absence of microscopic hematuria and degree of trauma. 95% of all patients with renal trauma have at least some hematuria > 5 RBCs/HPF. Children with microscopic >50 RBCs/HPF have low likelihood of significant renal injury. If only microscopic urine, can ignore if SBP<90, no severe decel injury, no gross blood (Am J Surg 1992, J Urol 1985)

CT with IV contrast most sensitive/specific. Urinary extravasation can’t be determined until contrast-enhanced urine is excreted into collecting system. Usually 10 minute delay. Focused ultrasound only identifies free intraperitoneal fluid. It does not specifically look for renal injury. Does not identify renal vascular injury as well.

Renal Grading system used for degree of injury. Nephrectomy in 82% of grade V injuries. Majority of renal injuries can be managed conservatively. If going non-operative route, make sure there’s no ureteral injury.

Renal exploration/intervention with expanding, pulsatile, non contained retroperitoneal hematoma and renal avulsion (grade V) injury.

Urinary extravasation alone is not indication for exploration as it usually spontaneously resolves (though this seems to be only retroperitoneal bladder injuries). Extravasation from renal pelvis or ureteral injury does need treatment.

Complications: AV fistula can occur and lead to delayed bleeding. Treat usually with embolization. Urinomas can occur a few weeks to years later and present with abdominal pain, mass, and fever. Perinephric abscess can present similarly.

Ureter Injuries

Protected in retroperitoneal. 90% occur with penetrating trauma. Only 70% have gross or microhematuria.

Partial tears can be scented. Most require operation, likely including percutaneous nephrectomy. Diagnosis with CT with IV contrast with 10 minute delay best for assessment.

Bladder Injuries

80% associated with pelvic fractures. Gross hematuria seem on 95%. Gross hematuria with pelvic fracture requires cystogram. Retrograde cystogram is gold stand. Bladder filled in retrograde fashion by gravity feed with enough contrast (350mL) to distend bladder (distended to attempt to dislodge thrombi on wall to accurately assess).

Extraperitoneal ruptures are most common. Intraperitoneal ruptures always require surgical exploration and repair – usually due to distended bladder with rupture at weakest point – dome of bladder. Extraperitoneal can be treated with foley and will likely heal in over 10 days. Need prophylactic antibiotics.

Urethral Injuries

Posterior urethral injury: high-riding prostate, usually due to major blunt trauma or pelvic fracture.

Anterior urethral injury: blunt trauma to peritoneum, blow to bulbar segment, saddle injury. Sometimes see ‘butterfly’ perineal hematoma from Buck’s fascia violation.

Look for blood at penile meatus. Don’t place foley due to possibly turning incomplete into complete tear. Will need retrograde urethrogram before cauterization. Gentle injection of 20-30mL of contrast into urethra with X-ray. Likely treatment emergently with suprapubic catheter.

Contrast/Jelly technique: 25cc of contrast and 25cc of KY jelly; mix in urine cup. Draw jelly into 60mL syringe. Under fluoro with oblique view, inset tip into penis and pull it toward yourself, pinching the meatus. Slowly inject contrast, watching to contrast column on fluoro screen. Once easy flow into bladder, can stop the study. If noted extravasation, stop study and call urology. One small study found one blind attempt didn’t have any major consequences (J Trauma, 2007)

External Genitalia Injury

Penile fracture: rupture of corpus cavernosum (pair of ‘muscles’ in dorsal aspect of penile shaft). Usually cracking sound, immediate detumescence, rapid swelling, discoloration and visible deformity. Penis will deviate away from side of injury – ‘eggplant deformity.’ Diagnosis made clinically. Need retrograde urethrogram. Can also use ultrasound for assessment. Treat with surgical exploration by urology. Dorsal artery/vein rupture can look similar and is called ‘false penile fracture.’ Still requires surgical exploration most times. Taghaandan – erect penis is forcibly pulled down to achieve detumescence – kurtish word for ‘to click.’ Can cause penile fractures.

Testicular contusions/rupture – tunica vaginitis fills with blood, forming hematocele. Color doppler is usually used for diagnosis. Treatment for testicular injury is conservative though still need urology consult for possible exploration.

All penetrating trauma to penis and testicles need surgery.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 262: Genitourinary Trauma

Rosens, Chapter 40: Genitourinary System

CrashingPatient.com, Genitourinary (GU) Trauma

262. Genitourinary Trauma

261. Penetrating trauma to the Flank and Buttocks

General

Flank is area between anterior and posterior axillary lines. Due to retroperitoneal region, delay in injury to duodenal, rectal, pancreatic and vascular structures can delay septic and hemorrhagic shock.

CT is imaging of choice. Consider doing rectal exam to look for blood in rectum. If peritonitis signs, IV antibiotic and surgical consult.

Exploratory laparotomy for GSW to flank usually. Stabs to flank are treated conservatively. Local wound exploration is less accurate in this region.

Penetrating Buttock Trauma

Usually GSW due to large musculature area. Stabs rare. 30% of buttock GSW need surgery. Can injure lower GU, GI, sometimes vascular.

Check neuro exam. Can hit femoral or sciatic nerve. Rare to hit plexus.

Cystourethrogram if blood in UA with wound close to GU system. Sometimes may need proctosigmoidoscopy if concern for colonic blood with rectal exam.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 261: Penetrating Trauma to the Flank and Buttock

Rosens, Chapter 39: Abdominal Trauma

261. Penetrating trauma to the Flank and Buttocks

260. Abdominal Trauma

Blunt Abdominal Trauma

MCC MVCs. Intraabdominal injuries rare with falls though if they do occur, they are usually hollow organ injuries. Also retroperitoneal injuries can occur.

CT not very good at diagnosing pancreatic, duodenal, mesentery, hollow viscous, diaphragm injuries.

Abdominal exams can be benign initially. Can have 50-60% of blood volume dumped in abdomen before symptoms noted. 35% of blunt trauma have initially ‘benign’ abdomen. Single exam is insensitive. Serial exams are important.

FAST > DPL though not perfect. 28% of negative FASTs have solid organ injuries without hemoperitoneum. DPL insensitive, invasive. No longer recommended though can be preferred in unstable patient unable to get to CT scan. Aspirate two finger breaths under umbilicus. Aspirate and if >10mL bright red blood, need laparotomy. Ultrasound can detect at least 100mL of blood. CT is snapshot, not dynamic imaging. CT not great for pancreas, diaphragm, small bowel, or mesentery.

Gray Turner sign: flank discolorization and Cullen’s sign: umbilicus discoloration are seen with retroperioteal bleeding though usually delayed signs.

Hepatic Injuries: 90% non-operative management if vitals stable. Grade I-III usually non-operative. Higher grade usually fail non-operative management. Angioembolization with stent/coiling useful for large hemoparioteum or contrast blush.

Splenic Injury: most common organ injured with blunt trauma. Failure rate 10-15% in non-operative management. Only non-op if patient < 55 and grade < IV. Proximal embolization can be useful and spleen will do well with collateral circulation.

Penetrating Abdominal Trauma

Small bowel most common organ injured followed by colon and liver. Liver most common injured in stabs though.

Stabs: LWE (local wound exploration) for anterior abdominal stabs is preferred over immediate laparotomy. CT also helpful. If no visualization of anterior fascia and likely negative CT with benign abdominal exam, can likely discharge. If hypotension, peritonitis or evisceration, will need laparotomy.

GSW: transabdominal GSW almost always need surgery. + FAST in 90%, though 1/3 of negative FAST will still need laparotomy. CT reliable in hemodynamic stable patient. Laparotomy for hypotension, abdominal wall disruption, or peritonitis.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 260: Abdominal Trauma

Rosens, Chapter 39: Abdominal Trauma

260. Abdominal Trauma

259. Cardiac Trauma

General

 

Blunt Cardiac Trauma

Usually from MVC from hitting steering wheel. Spectrum of concussion to contusion to infarction to rupture.

Myocardial concussion: also known as commotio cordis. Second MCC sudden death in athletes after HOCM. No structural heart disease on autopsies. Impact causes primarily electrical event causing ventricular fibrillation. Treatment includes bystander CPR and defibrillation. Need monitoring afterward with likely outpatient stress test, cardiac MRI, obviously no sports until cleared by cardiology.

Myocardial contusion: usually associated with other thoracic trauma (rib fractures, pulmonary contusions, etc). Most common sign: sinus tachycardia. Sometimes cardiogenic shock. Right ventricle most commonly affected due to it is the most anterior portion of the heart. New EKG abnormality usually means admission for observation and monitoring. Trop best biomarker. If negative EKG and biomarker, low suspicion for contusion. Consider pericarditis later on 2-3 weeks later with chest pain, fever and chest  wall blunt injury.

Myocardial rupture: almost always fatal. Right ventricle most commonly affected. usually patients survive long enough to the ED have intact pericardium with tamponade. Murmur harsh sounding, bruit de moulin – splashing-mill wheel – ‘pneumopericardium.’ Use ultrasound for diagnosis and will need emergent thoracotomy. CXR not great. Pericardiocentesis is usually only temporizing at best. If thoracotomy done, treatment with finger occlusion, foley, or staples.

Penetrating Cardiac Trauma

If survive to hospital, 80% mortality. Right ventricle most commonly injuries (43%), then left ventricle (34%), then atria after this. 5% have coronary artery involved. Either exsanguination usually from GSW and usually dead on scene vs pericardial tamponade most commonly seen with stab needing emergent thoracotomy.

Indications for emergent thoracotomy: cardiac arrest with initial signs of life or SBP < 50 after resuscitation in penetrating injury; cardiac arrest in the ED with blunt trauma.

Pericardial tamponade: stab > GSW, RV stab tend to seal themselves as well. Diagnosis with rapid ultrasound. Beck’s triad:distended neck veins, hypotension, distant heart sounds. Usually tachycardia first, then hypotension. EKG shows electrical alternans classically though this is usually only seen on chronic pericardial effusion. Pericardicentesis can be done and sometimes only 5-10mL of blood can drastically improve stroke volume temporarily. usually clotted blood though.

Thoracotomy: Left lateral incision in same area of chest tube (5th intercostal space at nipple/inframammary line) and extend to sternum. Can extend to right side with clam-shell technique going through sternum if considering right sided laceration if left side doesn’t show much. Excise pericardium anterior to phrenic nerve in vertical incision. Deliver heart from pericardium. If hole, use digital for pressure or foley or standard skin staples.

Blunt Aortic Injury

Usually due to sudden decal. Most common sites are aortic isthmus (just distal to left subclavian artery where aorta attached to ligament arteriosium) and proximal ascending aorta. CXR will show widened mediastinum (width > 8cm or mediastinum/chest width radio > 0.38) though not specific or sensitive. CT chest is preferred imaging. Careful regulation of BP and HR due to sheering forces – treat like medical aortic dissection. Treatment likely with synthetic graft endovascularly – may need vascular surgeon or IR rather than CT surgery. Complications after stunting can be later on dissection.

Questions

Q. Whats the most common site for blunt aortic injury?

A. Aorta isthmus. Wrong answers: Ascending aorta, distal descending aorta, site of coronary artery insertion

Q. Whats the most common EKG finding with myocardial contusion?

A. Sinus tachycardia. Wrong answers: PVCs, LBBB, RBBB, ventricular fibrillation.

References/Resources

Rosens, Second Edition, Chapter 38: Thoracic Trauma

Tintinalli, Seventh Edition, Chapter 258: Cardiac Trauma

What’s New in Trauma, William Mallon, AAEM Scientific Assembly 2017

259. Cardiac Trauma

258. Pulmonary Trauma

General

 

Chest Wall Injuries

Rib fractures: 50% of single rib fx missed on CXR. Main reason for considering rib fracture to assessing for other problems: hemopneumothorax, pulmonary contusion, intraabdominal injury. Main treatment is pain control. Usually break at point of impact or posterior angle/posterolateral due to weakest point of rib. Multiple rib fractures may need observation to assess pulmonary function in 1-2 days. Usually heal in 3-6 weeks.

NEXUS Chest CT Criteria for blunt trauma: Have to not have any of these to not need chest CT: abnormal CXR, rapid decal > 20 foot fall, MVC > 40mph, distracting painful injury, chest wall tenderness, sternal tenderness, thoracic spine tenderness, scapular tenderness. So basically every patient can’t be ruled out for chest CT.

Flail chest: free-floating segment of ribs.

Sternum fracture: usually body or manubrium. Very low incident of dysrythmias with mortality < 1%. If EKG and stable vital signs for 6 hours, no further cardiac workup.

Pulmonary Injuries

Pulmonary Contusion: usually high speed MVC. Due to direct injury to lung parenchyma and secondary associated with resuscitation with edema/hemorrhage. CXR may show patchy ground glass opacities in mild/moderate contusion. 70% won’t be seen on initial CXR. Contusion > 20% of lung are up to 80% risk of developing acute lung injury. Main treatment is pain control to maintain ventilation. If intubated, place non-injured lung down by turning patient to decubitus position. Also high-frequency oscillating ventilation.

Pulmonary hematomas: usually dissolve, though can be infected.

Pneumothorax: If asymptomatic thoracic stab wound and has  no pneumothorax, observe an repeat in 4-6 hours and if no pneumothorax, can discharge home. If patient needs intubation, air or long transportation, consider chest tube or small pleural catheter. If small pneumothorax < 1 cm width (confined to 1/3 chest), and unchanged at 4-6 hours and otherwise healthy, treat with observation. Ultrasound: M-mode over most superior portion of chest wall – look between ribs. “Seashore sign” is normal lung movement; “stratosphere sign” is abnormal sign or pneumothorax.

Chest tube placement: Anterior axillary line at level of nipple or infrmammory line in women (5th intercostal space). Oblique skin incision 1-2cm below interspace and go above rib to avoid nerve/artery. Oblique tunnel is to allow good closure of incision when tube removed preventing recurrent pneumothorax. Open rib 1.5-2cm, use finger when puncturing through on top of clamp and inspect to make sure lung isn’t attached to rib wall. If suspecting hemothorax, go large with 32-40Fr chest tube. Advance tube until 2.5-5cm past last hole in chest tube. Water suction at 20-30cm H20. If leaving ED, never clamp chest tube (can convert to tension pneumothorax). If unclamped, water seal bottle kept at 1-2 feet lower than patient’s chest. Chest tubes have been thought to may need prophylactic IV abx afterward.

Tension pneumothorax: clinical diagnosis with distended neck veins, hypotension/hypoperfusion, deviated trachea, decreased breath sounds. If suspected, immediate needle decompression with 14g need catheter into either midclavicular line above rib on 2nd intercostal space or laterally in same region as chest tube due to fall chest walls (study showing smaller depth on lateral aspect). ATLS will now recommend 5th IC space anterior axillary line over 2nd IC space in next edition (Laan, 2016) Need large bore chest tube after needle decompression.

Open pneumothorax: ‘sucking chest wound’ or even GSW. Do not pack (may have lung ‘inhale’ contents. Cover wound with 3-sided dressing so air can escape but cannot enter wound. Avoid complete occlusion which may cause tension pneumothorax.

Pneumomediastinum: look for Hamman sign: crunching sound over heart in diastole. Usually secondary to alveolar rupture with bronchioalveolar sheath dissection. Very often only require observation.

Tracheobronchial Injuries

Rapid decel injuries. Occurs usually within 2cm of carina. Can cause hemoptysis, subcutaneous empysema, SOB. All lacerations of branch > 1/3 circumference will likely require surgical repair. Most usually require bronchoscopy.

Diaphragmatic Injuries

Blunt trauma usually 3/4 left sided, 1/4 right sided. bowel can herniate and get strangulated/ischemia called a ‘tension enterothorax.’ Treatment always laparotomy.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 258: Pulmonary Trauma

Rosens, Second Edition, Chapter 38: Thoracic Trauma

Reimagining your Approach to Tension PTX, Zag Qasim, AAEM 2017

258. Pulmonary Trauma

257. Trauma to the Neck

General

Roon & Christenen classification: 3 zones. Zone I: clavicle to cricoid cartilage. Includes typical neck structure with lungs, thoracic duct. Vascular control difficult. If OR required, will need thoracic surgical approach usually. Zone II: cricoid cartilage to angle of mandible. Both proximal and distal vascular control can be controlled early. Not necessarily needing OR exploratory though likely will extensive wound, transcervical trajectory. Zone III: angle of mandible to base of skull. Treat as cranial injury. Vascular injury primarily the main cover. Selective, nonoperative management. Exploratory surgery not indicated.

Other classification involves anterior and posterior: Anterior triangle: posterior landmark is sternocleidomastoid muscle, clavicle is inferior landmark. Posterior triangle: posterior landmark is trapezius muscle – more favorable outcome with injuries to posterior than anterior triangle.

Most superficial structure beneath skin/subcutaneous tissue is the platysma muscle. Important landmark for penetrating neck trauma.

Hard signs: usually associated with significant injury: active hypotension, active arterial bleeding, diminished carotid pulse, expanding hematoma, thrill/bruit, lateralizing signs, hemothorax > 1L, air bubbling in wound, hemoptysis, hematemesis, tracheal deviation.

Soft signs: hypotension in the field, history of arterial bleeding, unexplained bradycardia, non expanding hematoma, stridor/hoarseness (though can be considered hard signs as well), vocal cord paralysis, subcutaneous emphysema, 7th CN injury.

Airway: intubate early. Better than delay with difficult intubation with patient in respiratory distress/distorted airway. Likely needing intubation: acute respiratory distress, airway obstruction from blood/secretions, massive subcutaneous emphysema, tracheal shit, AMS, expanding neck hematoma.

Breathing: consider hemo/pneumothorax in Zone I.

Circulation: direct pressure over bleeding; no clamping (can cause neuro injuries).

Disability: normal neuro exam with isolated penetrating trauma does not need C-spine immobilization.

Penetrating Trauma

Stab, GSW, shotgun, sharp objects. If platysma violated, assume significant injury. Never probe. Surgical consult likely needed. If hemodynamic unstable or obvious aerodynamic injury, immediate surgery. CTA for vascular injury; you can’t r/o esophageal or tracheal injury with CTA alone. Ultrasound (doppler or otherwise) pretty much useless.

Venous Air Embolism: can cause profound shock or cardiac arrest. If considering, place patient head down, left lateral decubitus position. This position tries to accumulate air into apex of right ventricle. After this, consider aspiration with either ultrasound guidance or thoracotomy.

Blunt Trauma

Clothesline injuries, direct blows, handlebars, near hangings (probably most common). Symptoms often minimal or delayed. Anatomic triangles are probably more important than zones. Think vascular and larynx injuries. Do CTA over CT soft tissue neck. When considering intubation, may consider whether or not to do paralytic agent due to paralysis may result in decreased muscle tone.

Cricothyroidoctomy should be avoided because it may worsen laryngeal injury. Consider vertebral artery injuries with cervical hyperextension, excessive contralateral rotation or both. 50% of dissections are asymptomatic initially. Neuro symptoms often delayed. Wallenburg syndrome: lateral medullary infarction syndrome: ipsilateral facial loss of pain/temp, isolated loss of CN V, IX, X, and XI, cerebellar ataxia, Horner’s syndrome, and body contralateral loss of pain/temp. If blunt vascular injury confirmed, will need to anticoagulant to prevent stroke or propagation. CTA better than MRA for vascular dissections. Consider endovascular stenting for severe dissection.

Thyroid hematomas can slowly expand and eventually cause airway compromise.

For asymptomatic patients, likely need to observe for at least 2 hours, more likely 4 hours before discharge.

When to consider CTA on neck trauma: ATLS 9th edition: C1-C3 fractures, fractures with subluxation, fracture thru foramen transversium. EAST: Neuro deficits, blunt injury with significant epistaxis, asymptomatic with RF: GCS < 8, petrous bone fracture, diffuse axonal injury, C1-C3 fracture and fracture through foramen transverse, Leforte Fractures. Denver Criteria:

Strangulation

Complete if freely suspended. Incomplete is everything else. If fall > length of body, likely cervical fracture causing likely Hangmans fracture with cervical cord transection leading to death.

Constriction causes jugular venous obstruction leading to brain ischemia leading to LOC and eventually death. Airway compromise isn’t main cause for death/LOC. Traumatic edema of larynx and supraglottic tissue can lead to airway compromise. Should consider with painful swallowing, severe hoarseness, stridor. Watch for pulmonary complications which is the most common cause of in-hospital mortality.

Tardieu spots: petechial hemorrhage seen in conjunctiva, mucus membranes, skin.

Esophageal Injuries

Most frequently missed injury in neck trauma. CTA does not diagnosis. Consider contrast esophagraphy with water-soluble contract (gastrograffin bad for lungs; barium bad for GI and mediastinum; consider omnipaque, ultraist, hexabrix). Barium more sensitive but dangerous with extravasation. Flexible endoscopy follows negative contrast study. Combo has sensitivity of 100%. If suspicious, start broad spectrum IV abx (Zosyn) and make NPO. Consider endoscopied placed NG for gastric content. Small contained injuries can be managed with observation/NPO.

Laryngotracheal Injuries

Cricoid cartilage is only complete ring in trachea. Calcification of laryngeal cartilage begins at teenage years leading to higher mortality in kids. Pain with tongue movement or rotation of head can be related to hyoid bone or laryngeal cartilage injury. Diagnosis with laryngoscopy. CT pretty good at detecting though.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 257: Trauma to the Neck

Rosens, Chapter 37: Neck Trauma

Which Neck Injuries Require Vascular Imaging, Eric Martin, 2015 Managing Medical Emergencies, EMedHome

CrashingPatient.com, Neck Trauma

Blunt Neck Trauma, William Mallon, AAEM Scientific Assembly 2017

257. Trauma to the Neck

256. Trauma to the Face

General

Check sensation throughout face, check typical eye physical exam findings (EOM, visual acuity, possible interocular pressure, pupil reactivity), ask about malocclusion.

Etomidate and Ketamine good for sedation with intubation in facial trauma due to preserved respiratory drive.

For significant hemorrhage, usually due to sphenopalatine and greater palatine branches of external carotid. Anterior pack first (no posterior packing due to possible intracranial involvement). If still persistent, consult for possible emergent surgery vs IR (anastomosis throughout face so low risk for ischemia). Worst case scenario would be to ligate external carotid.

Frontal Bone Fracture

High-energy mechanism. Increased risk of TBI. Operative repair for through and through fracture to prevent pneumocephalus, CSF leak, infection. isolated anterior table fracture can be discharged with f/u with facial surgeon though will still likely need surgery. Depressed fractures (through and through I’m assuming) usually require IV abx and operative repair.

Orbital Fractures

Blowout fractures: fracture of inferior/medial orbital walls causing adipose tissue, inferior rectus or inferior oblique muscle can herniate and become entrapped. Diplopia with upward gaze. Nano-orbito-ethmoid fracture results in pain with eye movement – needs consult, potential admission for facial/NSGY consult. Repair in 1-2 weeks with adults, children shorter time though consult in ED for possible emergent need depending on entrapment. In adults, fractures develop fibrous union at 10-14 days.

Isolated orbital fractures: Augmentin, decongestant, and avoiding blowing nose. Consider patch for diplopia.

Retrobulbar Hematoma: or malignant orbital emphysema. Can cause ocular compartment syndrome which can lead to ischemic optic neuropathy. Emergent canthotomy reduces ocular pressure and ischemia. Ocular ultrasound may show ‘guitar pick sign.’

Zygoma Fractures

Isolated temporal arch fractures: can be discharged. Will likely need surgery, can cause significant trismus.

Tripod Fracture: zygomatoicomaxillary fracture (zygoma, maxilla, orbit) – deceleration injury with disruption of zygomaticofacial suture, zygomaticotemporal junction, and infraorbital rim. Considered orbit/sinus fracture. Loss of vision or significant displacement requires admission for IV abx and operative repair.

Frontal sinus doesn’t develop until age 6. Maxillary sinus by age 10.

Midfacial Fractures

Facial Buttress concept – face is like scaffolding – 4 horizontal and 4 vertical struts – when 2 or more involved, likely unstable.

LeFort I: transverse fracture departing body of maxilla from pterygoid plate (always fractured in all of them) and nasal septum. Involves hard palate and teeth. Feels like loose upper dentures. Always involves nasal fossa. II: hard palate and nose occurs, though not eye involvement. Always involved inferior orbital rim III: entire face separated from skull. Entire face shifts with globes held in place. Always involves zygomatic arch. IV: LeFort III + frontal bone. Consider getting CTA head/neck for vascular injury for > LeFort II. Usually significant hemorrhage. Likely needs nasal packing. Treatment: Admission, IV abx, and surgical repair. Can have different LeForts for both sides.

Superior orbital fissure syndrome: encroachment on the CN involved within the orbital fissure: CN II (vision), CN III, IV, VI (EOM) and V (usually sensation to forehead – V1). Can look like muscle entrapment though usually diffuse ‘entrapment’ rather than just when looking up, etc. Consider starting steroids to decrease swelling. Needs urgent surgery – if CN II involved, needs emergent surgery – time is vision.

Midface bleeding almost always requires IR intervention rather than surgery. Pack first, then IR.

Mandible Fractures

Second most common facial fractures to nasal fractures. 36% at angle, 21% at body, and 17% at parasymphyoid. Usually multiple fractures with 1 at side of impact and the other on the other side due to ‘ring’ effect. Look for ‘open fracture’ with thorough oral exam. 42% are still unifocal fractures. If stable, place Barton’s bandage: ace wrap over top of head and underneath mandible. Open fractures: tx with abx for similar dental infections (PCN or clindamycin). Open fractures usually require operative repair.

Rapid bone remodeling with callous formation occurs by 1 weeks makes delayed reduction difficult. Usually prompt diagnosis and 1-2 day referral for pediatric facial surgeon.

Tongue blade test: stick blade in mouth and have patient clench with teeth and attempt to break off by twisting. Only 85% sensitive for ruling out mandible fracture.

Other Fractures

Nasal Fractures, Dental Fractures in ENT section. Same goes for facial lacerations.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 256: Trauma to the Face

Rosens, Chapter 35: Facial Trauma

CrashingPatient.com, Facial Trauma

Facial Trauma, Laura Bontemp, Maryland Trauma Day 2017

 

256. Trauma to the Face

255. Spine and Spinal Cord Trauma

General

Etiology of spinal cord injury: MVC (42%), falls (27%), violence (15%, mainly GSW).

Spinal stability: ability of spine to limit patterns of displacement that may damage spinal cord or nerve roots. Denis system: 3 lines: anterior portion of vertebral body; middle is posterior portion of vertebral body; posterior – boney complex of posterior vertebral arch. If 2 lines disrupted – unstable. Unstable also considered if cervical vertebral body compression > 25% or >50% in thoracic/lumbar.

Corticospinal Tract: descending motor pathway. Crosses from brain at medulaa so left sided lesion causes left sided weakness. Ipsalateral symptoms with spinal cord lesion.

Spinothalamic Injury: pain and temperature. If this region of spinal cord gets damaged, loss of pain/temperature on CONTRALATERAL side.

Dorsal columns: vibration/proprioception. Damage causes ipsalateral symptoms.

Anterior Cord Syndrome: damage to corticospinal and spinothalamic tracts causing loss of motor and pain/temp bilaterally below lesion. Caused by damage to anterior cord due to flexion or thrombosis. Poor prognosis.

Central Cord Syndrome: Older patients with cervical spondylosis with hyperextension. Damages corticospinal and spinothalamic tracts with upper extremities affected more than lower extremitites. Prognosis good though fine motor likely long term affected.

Brown-Sequard Syndrome: hemisection of cord. Ipsalateral loss of motor, proprioception/vibration, contralateral pain/temp. Due to penetrating injury. Best prognosis.

Complete Spinal Cord Lesions: absence of sensory/motor below level of injury. Includes loss of function to level of lowest sacral level. Priapism implies complete spinal cord injury. Incomplete if any sensory, motor, or both functions are partially present. Even if rectal tone or sacral sensation at anal region present, its consider incomplete.

Spinal Shock: Looks like complete and cannot differentiate until it resolves. Can persist for days/weeks. Bulbocavernous reflex: first reflex to return as shock resolves. Squeeze penis/clitorus causing anal tightening – can also be done by pulling on foley.

Neurogenic Shock: injury to spinal cord at cervical or thoracic vertebral causing loss of sympathetic arterial tone. Causing peripherally vasodilation, hypotensive with relative bradycardia. Flaccid with areflexia. If some neuro symptoms at all below, likely not neurogenic shock. This is diagnosis of exclusion. Treatment with IV fluids, MAP > 90. May need positive inotropes, atropine for significant bradycardia.

Penetrating Injuries: transperitoneal and transintestinal GSW to spine needs IV broad spectrum antibiotics. most are managed non-operatively. If progressive neuro deficits, will need surgical decompression. Bullet remova does not significantly improve neuro deficits of patients with stable cervical or thoracic spine. Bullet removal at T11-L2 may significantly improve motor recovery in both incomplete and complete spinal injuries.

Cervical Spine Injuries

NEXUS: National Emergency X-Radiography Utilization Study. No imaging of cervical spine if all 5 excluded. 99.6% sensitive, 12.9% specific. N (neuro deficit/paresthesis), E (Etoh), X (Xtreme injury/distracting injury), U (Unable to provide history, AMS), S (Spinal tenderness, midline).

Canadian Cervical Spine Rule for Radiography: 100% sensitive, 42.5% specific for ‘clinically important’ cervical spine injuries. Answer 3 questions: First one is making sure there are no high risk factors: age >65, dangerous mechanism (fall from >3ft, axial load, high speed MVC > 60mph, rollover, ejection, recreation vehicle or bicycle, paresthesis in arms). If all negative, next question requires any of the following to provide with safely doing ROM of the neck in the ED: simple rear-end, patient able to sit up in the ED, ambulatory at scene, delayed onset of neck pain, absence of midline tenderness. If ANY of these +, can procede to next question. Third question: Can patient rotate their neck 45 degrees to the left and to the right. If able to do this, no imaging necessary.

CT preferred over xray; CT doesn’t exclude ligamentous injury. Flex-Ext xray view used to assess spinal stability though not useful in the acute setting. High false positive/negative rate. If step off of 3.7mm or angulation > 11, considered unstable. If CT negative and still having persistent pain, recommend hard collar with f/u in 3-5 days with PCP or trauma surgeon.

Newer literature showing potential to clear with negative CT C-spine. EAST guidelines (2015) recommended obtunded patients with negative CT neck can have collar removed. New study of 10,000 pts showed only 3 missed injuries with negative CT c-spine and all had initial neuro exams likely consistent with central cord syndrome (Inaba, 2016).

If C1-C3 or transverse foramen fracture noted, 22% associated with vertebral artery dissection or thrombosis – likely need to get MRA or CTA.

Flexion Injuries

Anterior subluxation: Hyperflexion sprain/rupture. Ligament failure. Can be unstable though rarely have associated neuro deficits.

Bilateral facet dislocation: Disruption of all ligaments secondary to hyperflexion. Vertebral body dislocated anteriorly at least 50% of its width. Unstable. Usually neuro deficits. Forward movement causes inferior facets of upper vertebrae to pass up and over the superior facets of lower vertebrae.

Simple Wedge Fracture: superior endplate of vertebral body. Usually stable. If posterior displacement, consider burst and unstbale. Posterior ligament usually intact.

Spinous Process Avulsion (Clay-Shovelers) Fracture: Lower cervical, usually C7. Intense flexion. Stable. named after abrupt head flexion that clay miners experienced when lifting shoveful of clay and the clay stuck to shovel.

Flexion Teardrop Fracture: Anteroinferior pattern with complete ligament disruption. can cause anterior cord syndrome with neuro deficits. Highly unstable.

Occipitoatlantal Dissocation/Dislocation: skull displaced anteriorly or posteriorly. Usually death. If subluxed, look for basion/dens interval (BAI – basion anxial interval) > 12mm. Extremely unstable.

C2 (Odontoid) Fracture: 3 types: Type I is avulsion which is stable. Type II is most common type, odontoid body fracture – unstable. Type III is superior portion of body of C2 secondary to force with some angulation. Unstable as well.

Flexion/Rotation Injuries

Unilateral facet dislocation: Vertebral body will be displaced <50% of its width. Stable.

Vertebral Compression Injuries

Jefferson (burst) Fracture: C1 (Atlas) fracture. Axial load. Outward displacement of lateral masses on open-mouth view. Severe causes transverse ligament disruption. Usually unstable. Predental space (space on lateral xray between posterior C1 and anterior dens) < 3mm.

Burst Fracture: Retropulsion. Stable since usually ligaments intact though can be unstable if retropulsion penetrates spinal cord causing anterior cord syndrome.

Hyperextension Injuries

Hyperextension Dislocation: Usually facial trauma and central cord syndrome. May look normal on CT though with lots of soft tissue swelling from it being ‘reduced.’ Unstable.

Anterior Arch of Atlas Avulsion Fracture: Stable.

Posterior Arch of Atlas Fracture: Potentially unstable.

Extension Teardrop Fracture: Anteroinferior vertebral body avulsion fracture. Unstable.

Laminar Fracture: stable.

Traumatic Sponylolisthesis of Axis: Hangman’s Fracture. Fracture of both pedicles of C2 allows it to displace on C3. Unstable though rarely have neuro deficits. Called Hangmans because judicial haning had knot in front causing hyperextension.

Other Injuries

Uncinate Fracture: lateral flexion injury. Lateral superior edge of vertebral body. Can cause tranverse fracture. Ipsalateral neuro deficits. Stable.

Occipital Condyle Fracture: high-velocity injury, neuro impairment common. Neuro deficit or avulsion requires surgery.

Pillar Fracture: isolated vertical/oblique fracture though lateral mass. Extension/rotation injury. Unstable/stable depends on injury/severity.

Spinal Orthoses in cervical spine – restricts flexion/extension in middle/lower though lateral bending and rotational movements were poorly controlled. Hard collars include Philadelphia, Miami J. Gold standard is halo cervical immobilization: vest, halo ring pinned to skull and upright posts.

Thoracic Spine Injuries

Thoracic spine is rigid (T1-T10) and usually not injuried. If fracture, usually severe forces applied. Spinal cord narrowing at thoracic region though.

Thoracolumbar Spine Injuries

T11-L2 is transitional zones prone to stress/injury.

Compression Fracture: usually stable unless >50% compressed. Burst Fracture causes retropulsion of fragments and usually unstable.

Flexion-Distraction Fracture (Chance): seat-belt injury usually when lap-belt used only. Increased posterior vertebral body height, posterior wall body fracture, posterior opening of disc space. Look for anterior compression fracture of T11-L2 in ‘restrained’ patient. Usually unstable.

Immobilization of upper thoracic not always necessary but can provide additional comfort. Thoracolumbar jnction and lumbar regions are difficult to immobilize – remind patient to restrict movement.

Sacrum/Coccyx Injuries

Sacral fractures usually associated with pelvic fractures. If central sacral canal involved, can cause bowel/bladder issues.

Coccyx fracture can be made clinically with rectal exam. Don’t necessarily need xrays. Treatment symptomatically with analgesics and use rubber doughnut pillow.

Questions

 

References/Resource

Tintinalli, Seventh Edition, Chapter 255: Spine and Spinal Trauma

Rosens, Chapter 36: Spinal Trauma

Normal CT C-spine? MRI?, Eric Morley, AAEM 2017

255. Spine and Spinal Cord Trauma

254. Head Trauma in Adults and Children

General

TBI: Traumatic Brain Injury – impairment in brain function due to result of force. Either temporary or permanent. Mild: GCS 14-15, Moderate 9-13, Severe < 8.

Cranium is fixed volume made up of brain, CSF and blood. ICP < 15 in adults, children its less with infants being 1.5-6. Cerebral blood flow usually maintained if CPP < 60. CPP: Cerebral Perfusion Pressure – cerebral blow flow measured. CPP = MAP (DBP + (SBP-DBP)/3 – ICP

Cushing reflex: rapid rise in ICP causing triad: bradycardia, HTN, and irregular respirations. more common in children than adults.

GCS: 15 point scale used to assess TBI. Motor score correlates just as well as full GCS.

Mild TBI

“Concussion.” GCS 13-15 with either LOC, amnesia, dazed/confused period, or focal neuro deficit that may/may not be temporary. Can have normal CT and due to metabolic injury have significant symptoms/effects. CT positive in 15% though < 1% requiring NSGY intervention. Cognitive symptoms (most consistent abnormalities with mild TBI): attention difficulty, concentration, amnesia, orientation, altered reaction time, calculation issues. Physical symptoms: headache, dizziness, insomnia, fatigue, uneven gait, nausea/vomiting, blurred vision, olfactory nerve abnormality most common CN affected. Behavioral symptoms: depression irritability, anxiety, sleep disturbance. Symptoms can occur immediately afterward or delayed for days/weeks. No pharmacological treatment. “Brain rest”, NSAIDs, hydration. Complete resolution in 80% by 6 weeks. Most common lingering symptoms: headache, difficulty concentrating, memory difficulties.

New Orleans Criteria and Canadian CT are 100% sensitive on finding NSGY interventional findings on CT. LOC/amnesia is required as starting point before considering studies though. New Orleans more sensitive at ANY CT finding.

Sports: Most common concussion sports are football, ice hockey, soccer, lacrosse. SCAT3 (Sports Concussion Assessment Tool) for ages > 13 (ChildSCAT3 for 5-12). Takes 15-20 minutes to complete. No return to play after concussion that day. Requires stepwise approach to go return to play – at minimum 1 week to get through steps asymptomatic.

Second Impact Syndrome: rapid edema and and death if second injury before first injury has fully resolved. Rare. First cases didn’t really have a ‘second’ impact.

Post-concussive syndrome: persistent symptoms for months/years. 20-40% have symptoms at 3 months, 15% at 1 year. Usually associated with previous migraine history, depression/anxiety. If symptoms persist for more than 3 weeks, need to see concussion clinic/specialist.

Moderate / Severe TBI

3 goals: prevent further secondary brain injury, identify treatable mass lesions, and identify other life-threatening injuries.

Prevent secondary brain injury: correct/treat hypoxia/hypotension (2x mortality, single incident of either one increases mortality 150%, keep SBP >90, MAP > 80), anemia, hyperglycemia, hyperthermia.

Induction agents for intubation: Etomidate 0.3mg/kg – rapid onset (45 seconds), short acting (3-5min), favorably hemodynamically stable, reduces ICP. Adrenal suppression with continuous use.  Propofol 1-3mg/kg – anti seizure properties, boluses can cause hypotension.

Decorticate posturing: “to the core” – arms flexed/legs extended. Injury above midbrain.

Decerebrate posturing: arms extended and internal rotated wrists – more caudal injury, worse prognosis.

Elevated ICP treatment: Oxygen saturation > 95%, PaCO2 35-40, elevated head of bed to 30 degrees (reverse trendelberg in spinal precautions), keep neck straight. Mannitol: reduces ICP quickly and last 6 hours. .25mg-1g/kg. No dose-dependent effect. Net intravascular volume loss – acts as diuretic. Hypertonic saline: less studied than mannitol – no preferred benefit over mannitol. 23.4% 30mL though needs central line to give. Hyperventilation: no longer recommended unless very temporizing before surgery. Steroids not recommended. Seizure prophylaxis: NSGY dependent, Fosphenytoin or Keppra. Definitely give in penetrating trauma.

Skull Fractures

Linear skull fractures with overlying laceration are open fractures requiring NSGY consult. Vancomycin + Ceftriaxone 2g. Linear skull fractures along dural sinus or middle meningeal artery – watch for signs of epidural hematoma formation.

Skull fracture open/depressed with sinus can cause intracranial air (pneumocephalus) – needs IV abs with Vancomycin/Rocephin.

Basilar Skull Fractures: most common region is temporal bone – petrous portion. Associated with torn dura causing otorrhea or rhinorrhea. CSF otorrhea/rhinorrhea, mastoid ecchymosis (Battle sign), periorbital ecchymosis (raccoon eyes), hemotympanic membrane, vertigo, decreased hearing and 7th CN palsy. Possible CSF leak – collect fluid and check for beta-transferrin (only found in CSF) – Ring sign on paper not accurate/reliable. Acute CSF leaks are at increased risk for meningitis though no abx prophylaxis needed initially. Sometimes spontaneously close – up to NSGY/ENT. Persistent > 1 week leaks require abx and surgery.

Brain Herniations

Uncal Hernation: most common type. Temporal lobe uncus displaces inferiorly through medial edge of tentorium causing compression of CNIII (parasymptomatic nerves first) – ipsilateral sluggish pupil/dilation with contralateral motor weakness. Kernohan’s notch syndrome: contralateral cerebral peduncle is forced against the opposite edge of the tentorium hiatus causing ipsilateral hemiparesis.

Central Transtentorial Hernation: initial pinpoint pupils, bilateral babinski, increased muscle tone. usually decorticate posturing as well. Expanding lesions at vertex/frontal/occipital poles with bilateral central pressure.

Cerebellotonsillar Herniation: cerebellar tonsil herniates through foramen magnum. Pinpoint pupils, flaccid paralysis, sudden death.

Upward Transtentorial Hernation: posterior fossa lesion causing pinpoint pupils, conjugate downward gaze with absence of vertical eye movements.

Cerebral Contusion

Contusion in subfrontal cortex. Associated with SAH. ICH can occur days after contusion. Usually no NSGY intervention.

Traumatic Subarachnoid Hemorrhage

Most common CT abnormality with moderate/severe TBI. CT 6-8 hours after injury more sensitive. Risk factor for early mortality.

Epidural Hematoma

Blood between skull and dura mater. Associated with middle meningeal artery. Classic presentation with head injury with LOC, followed by lucid period and then rapid decline. Strikes to lateral skull (baseball, pool stick). Biconvex hematoma in temporal region usually. Not usually crossing sutures/midline. Can lead to herniation within hours. Full recovery if hematoma evacuated prior to herniation or neuro deficits. Look for linear skull fracture along dura sinus or middle meningeal artery. Surgery for mass effect or hematoma > 30cm, or comatose.

Subdural Hematoma

Sudden accel/decel of brain parenchyma. Tearing of bridging veins. Blood between dura and arachnoid space. SDH associated with other brain injuries. Elderly and children < 2yo at risk. Subacute: is odense on CT. Chronic: hypodense. Treatment varies. NSGY intervention for >10mm or midline shift > 5mm, worsening GCS dilated/fixed pupils, elevated ICP.

Subdural Hygroma: collection of clear, xanthochromic blood tinged fluid in dura – sometimes from CSF escape from injuried vessels. Can occur immediately or in delayed manner.

Diffuse/Traumatic Axonal Injury

Disruption of axonal fibers in white matter/brain stem secondary to shear forces. Usually blunt trauma. Edema can develop rapidly. CT can be normal initially but classically CT shows punctuate hemorrhage. Treatment is preventing secondary injury. Usually present in coma with ‘normal’ CT. Time will show how severe TAI is as patient either improves from comatose state.

Penetrating Injury

GCS >8 with reactive pupils have only 25% mortality. GCS < 5 100% mortality. Prophylaxis abx needed with Ceftriaxone 2g. Stab wounds very low mortality relative to GSW. Impaled objets should be left in until surgery removes. Projectiles that cross midline or center of brain, pass through ventricles or rest in posterior fossa have high mortality.

Non-Accidental Trauma

Subdural Hematoma associated with NAT in infants. Look for concurrent retinal hemorrhages. 50% of SDH were related to NAT. Only 10% accidental.

Coagulopathy

4x poorer outcome with elevated INR. ICH with warfarin has mortality of 82%. Negative CT with coagulation is reassuring though delayed hemorrhage is reported. Not necessary to observe if clinically well appearing – rebleeding/delayed bleeding can occur at 24 hours or up to 4 weeks after. TXA for systemic hemorrhage – not recommended for isolated brain injury. Idarucizumab used for reversal of dabigatran (5g total, 2.5g x 2). Antiplatelet therapy are more likely for acute bleeding over delayed bleeding like warfarin.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 254: Head Trauma in Adults/Children

Rosens, Chapter 34: Head Trauma

254. Head Trauma in Adults and Children