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Emergency - Quality, Education and Safety

Teleconference

Head and Neck Trauma Cases

Dr Lisa Lee-Horn | Advanced Trainee | Emergency Care Institute

26 June 2019

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House rules

Confidentiality

Respect

AGENDA

• Case reviews

• Underlying causes

• NSW Health guidance

Participation encouraged throughout

(But please turn off camera & mute mic when not talking)

Case 1 – Initial presentation

• BAT CALL: 22yo man BIBA 130hrs from a nearby family party with stab

wounds to the neck, back and multiple defence wounds to his hands

• M- Multiple stab wounds

• I – Injuries sustained to neck, back, hands, arms, blood loss ~2L

• S – Intoxicated, agitated, fluctuating GCS 8-10, SBP 90, HR 110, Sats 96%,

RR 27

• T – Ventilation support BVM, one large bore IVC, 500ml Hartmans given,

direct pressure to wounds

NSW Rural Adult Emergency Clinical Guidelines

Case 1 – Presentation

• Full trauma call: Anaesthetics, General Surgical and ED registrars

assembled

• Primary Survey:

• Slim Indigenous man, GCS 8

• Pt initiating own breaths, possible threatened airway, ?sucking,

oozing neck wound

• Assisted ventilation with BVM

• One vascular access

• Initial ED obs:

• P100

• BP 100/70

• RR 22

• Sats 99% 15L BVM

How to assess a neck wound

• Zones:

• Zone 1 Sternal notch

to cricoid cartilage

• Zone 2 Cricoid to

angle of mandible

• Zone 3 angle of

mandible to base of

skull

Penetrating Neck Injuries• Injuries mostly (~80%) occur in Zone 2. ~10% of injuries involve two zones

• Zone 1 important structures: aortic arch, proximal common carotid arteries,

vertebral arteries, subclavian vessels, innominate vessels, lung apices,

oesophagus, trachea, brachial plexus and thoracic duct.

• Zone 2 important structures: common, internal and external carotid arteries,

internal and external jugular veins, larynx, hypopharynx and proximal

oesophagus.

•

Zone 3 important structures: internal carotid artery, vertebral artery, external

carotid artery, jugular veins, prevertebral venous plexus and facial nerve

trunk.

Assessment of Penetrating Neck Wounds

The platysma muscle provides a

barrier between superficial and

deeper layers of the neck.

Breeching this muscle increases the

risk of damaging deeper structures.

Needs careful clinical evaluation.

Majority require surgical exploration.

Assessment of Penetrating Neck Wounds

Hard signs associated with 90% rate of major injury

Hard Signs Soft Signs Airway compromise Haemoptysis

Expanding or pulsatile haematoma Oropharyngeal blood

Active, brisk bleeding Dyspnoea

Haemorrhagic shock/ HD instability Dysphagia

Neurologic deficit Non-expanding haematoma

Air bubbling through wound Vascular bruit/thrill

Crepitus, subcut or mediastinal emphysema

Management - Immediate

Focus on immediate life-threats:

• Asphyxiation from airway obstruction

• Any patient with hard signs of injury should be emergently brought to

an operating room for further management.

• Delays should only occur for securing the unstable airway

• Exsanguination

• Can apply direct pressure to bleeding wounds en route. May need to

consider a Foley catheter for tamponade.

• 80% of morality secondary to cerebral infarction

• ~ 20% of mortality secondary to uncontrolled haemorrhage

Airway

• Anticipate difficulties

• Prep the anterior neck for surgical airway

• Careful placement of the ETT and consider a smaller tube size to minimize

secondary injury

• Minimise bag valve mask (BVM) ventilation as it can cause dissection of

air into the neck and worsen airway distortion

• Cervical spine immobilisation is unnecessary unless the trajectory suggests

direct spinal cord injury (very rare) and may be harmful

• Can obscure neck injuries

• Make airway visualisation more difficult

• Delay definitive airway stabilisation

• Clear the neck with NEXUS criteria

Breathing• Zone I injuries and injuries that traverse zones can result in pneumothorax

Circulation

• DO NOT PROBE wounds with active bleeding as may dislodge clot

• Vascular injuries are the most common cause of mortality

• If possible, put vascular access on the contralateral side to the injury

• Apply direct pressure

• If direct pressure cannot control bleeding, placement of a Foley catheter and

balloon inflation may be successful in tamponade of bleeding as a

temporising measure

Diagnostic Imaging

• If stable, a portable chest x-ray, as well as AP/lateral views of the neck

should be obtained – to look for PTX, foreign bodies, soft tissue swelling, or

air outside

• CTA has overtaken angiography as the first test ordered, as it is faster, less

expensive, and non-invasive.

• Sensitivity of multi-detector CT angiography is 90-100%, when compared to

conventional angiography and surgical exploration the trachea

Diagnostic Imaging

• Oesophageal injuries are often clinically silent, so they ought to be

investigated and ruled out. They are a common cause of delayed mortality

eg. mediastinitis

• Plain x-rays do not exclude injury to the oesophagus.

• Contrast-enhanced oesophagraphy has a sensitivity of 89%, with rigid

endoscopy having a similar sensitivity. Flexible endoscopy has a lower

diagnostic yield than rigid endoscopy, but has a lower complication rate (i.e.

less iatrogenic perforation).

• When both contrast-enhanced imaging and endoscopy are used,

sensitivity approaches 100%

Disposition

• Patients with hard signs of aerodigestive or neurovascular injuries will require

emergency surgery

• Patients with soft signs of aerodigestive or neurovascular injuries will move

on to further imaging and should be admitted to a trauma surgery service (or

transferred to one)

• Patients with neither hard nor soft signs of aerodigestive or neurovascular

injuries may have imaging or, may simply be observed depending on local

protocols

Disposition

Reference Sperry 2013

Our Patient – Secondary Survey

• CDA believe pt had lost up to 2L blood on scene.

• Moving all 4 limbs. Agitated and intoxicated.

• Sucking wound at R lateral neck with subcutaneous emphysema overlying

most of R chest.

• CDA advised that there was a stab wound at posterior neck and L scapular

region also. Log roll delayed until after intubation.

• Deep wounds to R index finger and L forearm.

• Second Vasc access and art line inserted.

• FAST scan negative.

Our Patient – Initial Management

• Given one unit PC & tranexamic acid immediately on arrival to ED.

Remained HD stable.

• Promptly intubated with ketamine and rocuronium. Visually clear airway.

• Mobile CXR

• Confirmed ET placement.

• Small pneumothorax on L, chest drain inserted.

• CTA of neck completed. No vascular injury.

• Clinically suspicious of aerodigestive injury.

• IV Abx commenced. Tetanus prophylaxis given.

• Admitted under Trauma Surgery, close clinical observation in ICU.

• For OT the following day.

Questions?

Sperry 2013

Case 2 - Presentation

BAT Call

• 54 year old man with reduced GCS following a fall from a ladder.

• BP 220/120

• P 55

• Sats 95% on 15L NRB

• RR 12

• Temp 34.1

Case 2 - History

• Found in the garden lying on concrete after cleaning leaves from a gutter.

• Last seen 3 hours ago

• He has obvious signs of external head trauma, bleeding from his left ear and

has epistaxis.

• GCS is 7

• BSL 6.7

• Unequal pupils

• He is on warfarin for AF, no other medications.

• 2 IV lines by CDA

M - fall from ladder

I – likely TBI, high risk internal

injuries, on anticoagulant

S – GCS 7, BP 220/120, HR 55,

unequal pupils,

Sat 95% 15L NRB, RR 20

T – ventilation support BVM, one

large bore IVC, hard collar

in situ, Guedel airway

Grading of TBI

• Severe:

• GCS ≤ 8

• Moderate:

• GCS 9-12

• Mild:

• GCS 13-15

Primary Survey

• A: appears clear, hard collar

• B: supported with BVM, Sats 95%

15L

• C: 220/120mmHg, HR 55

• D: GCS 7, Uneven, reactive

pupils, Obvious signs TBI, some

movement noted of all limbs,

normal BSL

• E: No other obvious injury, cool

Case 2 - Resus

• Warming lamp

• Ventilation supported with BVM, not consistently initiating breaths

• Guedels put in during Primary survey, NP tube avoided for risk of BOS

fracture

• Promptly intubated

• MILS

• Ketamine and rocuronium

• FAST scan negative

• Sent for trauma CT pan-scan → 2 fractured lower ribs on the left

• AND

CT Brain Findings

• Bilateral frontal subdural haemorrhages

• Multiple well defined hyerdensities in the frontal and temporal regions

(contusions)

• Frontal subfalcine displacement/midline shift

• Subarachnoid blood

• Effacement of Right lateral ventricle

• Temporal bone fracture involving mastoid and external auditory canal

• Pneumocephaly left temporoccipital lobe

Traumatic Brain Injury – Initial Resus

• Primary vs Secondary injury

• Preventing secondary brain injury hinges on good general resuscitation and

avoiding hypoxia and hypotension.

• Should assume there is concomitant cervical spine fracture; keep in mind

whilst securing the airway.

• Imaging should be performed as soon as possible after the initial

resuscitation to identify any surgically treatable lesions.

• Are there other life threats besides the head trauma?

• Early consultation with Neurosurgery and Retrieval services if necessary

Airway and Breathing

• Indications for intubation:

• Not maintaining airway, oxygenation or ventilation

• Rapidly progressive deterioration

• Unable to obtain needed brain imaging due to agitation

• Need for surgery

• Prior to intubation

• Consider rapidly reversible reasons for a decreased mental status (ie.

Glucose, narcotics, ETOH)

• Perform a gross neurological assessment (GCS, Pupillary size and

response to light, movement of all 4 limbs)

Airway and Breathing

• Maintain position in reverse Trendelenburg of 20 degrees before and after

RSI. Improves preoxygenation and prevents rises in ICP by gravity and by

promoting venous drainage

• RSI medications

• Ketamine for sedation

• Succinylcholine or rocuronium

Ventilation

• Aim normal Pa CO2

• Low PaCO2 causes vasoconstriction which can cause cerebral

ischemia

• High PaCO2 can cause hyperemia and increase ICP

• Ventilator settings, particularly the RR, have a huge effect on PaCO2

• Aim for normal ventilation to maintain a normal PaCO2 (35-40 mm Hg)

• Hyperventilation is now reserved for the setting of impending herniation when

no other options to lower ICP are available

Oxygenation

• PEEP 5-12cmH2O

• Aim for normal PaO2 (100-150-mmHg) and AVOID hyperoxia (thought to be

toxic)

Circulation

ICP

• The pressure in the skull

• Increased ICP causes herniation

• ICP cannot be measured directly in the ED without an intracranial monitor,

but the physical examination and CT imaging gives us clues

CPP

• CPP = MAP - ICP

• In the injured brain, autoregulation is impaired, so changes in MAP are felt

more directly by the brain

• If the CPP falls too low, ischemia and infarction of uninjured brain can occur

DisabilityPerform serial neuro assessments

• Clinical signs of progressive deterioration or herniation (decreasing GCS,

pupillary changes and paralysis/posturing)

• Cushing’s Reflex: Bradycardia, Hypotension, Irregular breathing

Osmotic diuresis

• Reduce oedema in a patient at risk for brain herniation

• Mannitol

• Dose is 0.25 g/kg to 1.0 g/kg

• Monitor for hypotension and urine output

• Hypertonic saline

• Used in patients with concomitant hypotension

• Boluses of 3-5mL /kg

Disability

Seizure prophylaxis

• Phenytoin and levetiracetam are commonly used but it is unclear if these are

effective

• May not be commenced in ED unless a seizure occurs

• No evidence for steroids

• No evidence for prophylactic hypothermia

• Any benefit of prophylactic hypothermia appears to be outweighed by

its risks

• Aim Normothermia

Who Needs Imaging?

• LOC for > 5 minutes

• Focal neurological findings

• Seizure

• Failure of mental status to improve over time in an alcohol-intoxicated patient

• Penetrating skull injuries

• Signs of a basal or depressed skull fracture

• Coagulopathy

• Previous shunt-treated hydrocephalus

• Age > 60

Who Needs Imaging?

• Canadian Head CT Rule

• PECARN rule for children

• Use Mcalc

• Choose Wisely (RANZCR)

Who Needs Imaging?

http://www.choosingwisely.org.au/getmedia/59b0d1ff-afd8-4abe-8f9e-

199431680f74/RANZCR-Clinical-Decision-Rules.pdf.aspx

Retrieval

• 15 min obs whilst waiting for retrieval including neuro obs

• Arrange C-spine and CXR X-rays if able

• Dress wounds

• Give IV Abx, blood/fluids

• Baseline ECG

• Have IV antihypertensive prepared if necessary

Types of TBI

Epidural hematoma (EDH)

• Blow to the head

• Usually from middle meningeal artery tear with

associated skull fracture

• Often temporal or parietal

• Classic lenticular shape limited by the suture lines

• Classic presentation is an initial loss of

consciousness, followed by a lucid period, then a

secondary neurological deterioration

• Management involves emergent neurosurgical

consultation and surgical evacuation

Types of TBI

Subdural hematoma (SDH)

• Sudden deceleration injury, resulting in tearing of

the bridging veins

• Common in older patients

• Bleeding more commonly venous, it may ooze

slowly and only become symptomatic days -

weeks after the initial injury

• CT: white crescent shaped lesion on the

convexities of the skull which doesn’t cross the

midline. With time blood turns isodense with the

brain tissue (typically around 2 weeks post injury)

• Management involves emergent neurosurgical

consultation and surgical evacuation

Types of TBI

Traumatic subarachnoid hemorrhage (SAH)

• Shearing of blood vessels in the subarachnoid

space on the periphery of the brain in the cerebral

sulci

• Large traumatic SAH may dissect into the

ventricles, causing hydrocephalus

• Rebleeding is common

Types of TBI

Diffuse axonal injury (DAI)

• DAI is a primary brain injury

• Shearing of axons in the deep white matter at the instant of the traumatic

deceleration

• Typical clinical picture is of a comatose patient with no or minimal signs on

the initial CT; MR will detect the extent of injury

• Devastating and can progress to massive swelling and herniation in the

hours and days after injury

• Treatment is supportive

Types of TBI

Cerebral contusions/hematomas

• Cerebral contusions are collections of blood within

the brain parenchyma

• CT: white lesions with surrounding oedema (darker

appearance)

• These lesions may expand over time and may

result in mass effect and herniation

• Lesions are often not amenable to surgical

evacuation

• Serial CT imaging is critical to monitor the

progression of these lesions

Management of this patientClinical Priorities Actions

Airway Protection/

Oxygenation/Control of CO2

Intubated with Ketamine & Rocuronium

Ventilate to keep CO2 normal

Aim O2 Sats 94-98%

Reduce Intracerebral Pressure/Treat

Coning

Given Mannitol 1g/kg IV

(3% saline 3mls/kg)

Optimise venous drainage by nursing 30%

head up and taping ETT

Heavy ongoing sedation and paralysis

Reversal of Anticoagulation Prothrombinex – 25ml/kg

FFP

Vit K 5-10mg Iv

BP Management

<160/100 (this will vary btw LHD)

Mannitol will contribute

Analgesia

Aim MAP 80-90

Titrate IV anti-hypertensive eg. labetolol ,

hydralazine

Avoid hypotension (SBP <90), use NA

infusion if necessary

QUESTIONS?

Case 3

• Call from a rural hospital 50km away regarding a 24yo female who has dived

into a backyard pool and presented with neck pain. She was assisted out of

the pool and carried to the car. She has no obvious neurology or injury.

• GCS 15, nil LOC

• She has had analgesia

• No CT is available, plain radiographs of the C-Spine completed

• Jefferson fracture - a burst fracture of the atlas.

• Treat as unstable fracture in ED.

• Jefferson fracture is not normally associated with neurological deficit

although spinal cord injury may occur if there is a retropulsed

fragment affecting the cervical cord.

• 50% are associated with other C-spine injuries.

• 33% are associated with a C2 fracture.

• Can have vascular injuries of the neck.

• Look for other injuries (head, extremity).

Who needs C-spine immobilisation?

• Neck pain or neurological symptoms

• Altered level of consciousness

• Significant blunt injury above the level of the clavicles

How?

• Application of sand bags and head tape

Who needs C-spine imaging?INCLUSION CRITERIA

• Adults (defined as >16 years of age);

AND

• Acute trauma to the head or neck;

AND

• HD Stable; AND

• GCS=15; AND

• Injury within previous 48 hours; AND

EITHER

• Neck pain; OR Visible injury above

the clavicles; OR • Non-ambulatory;

OR • Dangerous mechanism of injury

EXCLUSION CRITERIA

• Trivial injuries

• Penetrating trauma

• Presented with acute paralysis

• Known vertebral disease (e.g. AS,

RA, previous cervical surgery)

• Returned to ED for reassessment of

same injury

• Pregnancy

Who needs C-spine imaging?

Spinal Cord Injury

• After injury, the SC becomes oedematous and normal neurological function

rapidly becomes compromised.

• Motor and sensory neurological deficits.

• May be unilateral or bilateral, affecting upper and/or lower body regions.

• Conscious patients may describe various perceptions such as numbness,

burning pain or absence of feeling or movement.

• Engage retrieval services promptly.

Primary vs Secondary Injury

Primary:

• From blunt or penetrating mechanisms at the time of the initial traumatic

event (eg. fractures, dislocations, hematomas, disrupted blood supply or

transection).

Secondary

• Due to mechanical instability contributing to ongoing direct injury, or insults

from other factors such as hypoxia and hypoperfusion.

• May be due to associated injuries, respiratory insufficiency and neurogenic

shock.

Much of the acute management of spinal cord injury is aimed at preventing

secondary spinal cord injury.

Resus: A & B

Respiratory Insufficiency

• High cervical injuries → airway obstruction due to local hematoma and

swelling.

• Lesions at the C5 level or higher lead to diaphragmatic paresis or paralysis

(phrenic nerve).

• Thoracic or higher lesions → paralysis of intercostal muscles, as the

intercostal nerves arise from the T1-12 levels

Resus A & B

Respiratory Insufficiency:

• Coexistent thoracic injuries

• Coexistent TBI (e.g. decreased respiratory drive)

• Complications of SCI (e.g. aspiration, atelectasis, metabolic acidosis from

spinal shock)

• Complications of treatment (e.g. sedation, fluid overload, transfusion-

associated acute lung injury, ventilator associated pneumonia).

Resus A & B

• Consider early intubation if there are any signs of:

• Decreased level of consciousness, an uncooperative/combative

patient leading to distress and further risk of injury

• Pending airway obstruction: stridor, hoarse voice

• Apnoea or respiratory failure due to paralysis

• Prophylactic, pre‐treatment of quadriplegic and high-paraplegic patients with

atropine is indicated prior to airway management due to unopposed vagal

tone and the risk of bradycardia during pharyngeal stimulation

Resus Circulation

• 2 large bore IVC, commence IVF

• Volume resuscitation is important → hypotension should be avoided

(maintain SBP >90mmHg, MAP >65)

• Any hypotension in a trauma patient should be assumed to be

hypovolaemic in origin until proven otherwise, even in a patient with an

overt spinal injury.

• Sources of bleeding must be aggressively sought and controlled.

• E-FAST if possible

Resus: Disability

• As per TBI

• Highest level motor, sensory, reflexes intact.

• Identify cervical spinal injury in primary assessment is important.

• Priapism (>C6 injury), diaphragmatic breathing and loss of anal tone

are key signs of high spinal cord compromise.

• Combative patients should not be physically restrained due to the increase in

leverage and potential for further injury.

• Sedation, intubation and ventilation may be indicated to manage severe

agitation

Resus: Disability

Resus: Exposure

• SCI patient can become hypothermic due to the loss of autonomic regulation

• Monitor temperature and keep them in a warm environment

Neurogenic vs Spinal Shock

Neurogenic shock

• Hypotension, bradycardia and peripheral vasodilatation.

• Loss of vasomotor and sympathetic nervous system tone or function. Occurs

when a significant proportion of the sympathetic nervous system has been

damaged.

• Lesions >T6 level.

• The patient’s vital signs are consistent with neurogenic shock.

Spinal shock

• Not true shock.

• Flaccid areflexia that lasts hours to weeks.

• Priapism may be present.

Questions?

CLINICAL TOOLS AND GUIDELINES

E-QuESTs so far

•Dangerous Back Pains

•Opthalmological emergencies

•Pulmonary Embolus

•Paediatric Increased WOB

•Atypical Chest Pain - ACS

•Sepsis in the elderly

•Abdominal pain in the elderly - AAA

& Ischaemic gut

•Scrotal emergencies

•Deadly headaches

•Paediatric deterioration

•Head injuries

Looking to next month, please…

•Share your cases

•Share your patient safety actions

•Spread the word with your colleagues

(or send me their email: lisa.leehorn@health.nsw.gov.au)

What would you like to see / hear about?

Level 4, 67 Albert Avenue

Chatswood NSW 2067

PO Box 699

Chatswood NSW 2057

T + 61 2 9464 4666

F + 61 2 9464 4728

aci-info@health.nsw.gov.au

www.aci.health.nsw.gov.au

Many thanks!

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