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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
Thanks for joining
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: [email protected])
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
www.aci.health.nsw.gov.au
Many thanks!
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31 July 08:00 am
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