1. Neck trauma Jasmin Fauteux August 25 th, 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 HardSoft Respiratory distressLTSubcutaneous emphysemaLT/PE Air bubbling neck woundLTHoarsenessLT Major hemoptysisLTMinor hemoptysisLT Severe active bleedingVascMinor bleedingVasc Large expanding hematomaVascSmall to moderate hematomaVasc Diminished/absent pulseVascProximity woundsVasc Unexplained hypotensionVascHypotension responding to fluidsVasc BruitVascPainful swallowingPE HematemesisPE 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. C-spine precautions Normal neurologic exam in penetrating trauma does NOT require 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 CNo 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 yo M, restrained, driver vs moose ATalking full sentences, trachea central BGAEB, SaO2 = 99% RA CGood pulses bilat, BP = 124/76, HR = 88 DGCS = 15, PERL at 3mm, MA4L EC-spine collar Neck abrasion

24. Blunt trauma

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

26. 20-30% of pts have no identifiable criterias and 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 hanging Judicial vs n-judicial Complete vs incomplete

33. ABC’s ALMA in place, bagged, good chest rise BGAEB, Sa02 = 98% CNSR, BP = 80/40 DPupils fixed at 2mm, GCS = 3 EC-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 Rohan Lall Chad Ball Monica Hoy Lee Graham