01-2 Trauma - Head, Neck, Chest Flashcards
(39 cards)
An 18-year-old man arrives in the ER with an ax firmly implanted into his head. Although it is clear from the size of the ax blade and the penetration that he has sustained an intracranial wound, he is awake and alert and hemodynamically stable.
The management of penetrating wounds is fairly straightforward. There will be exceptions, but as a rule the damage done to the internal organs (in this case the brain) will need to be repaired surgically. This man will go to the OR, and it will be there, under anesthesia and with full control, that the ax will be removed. An important detail when the weapon is embedded in the patient and part of it is sticking out is not to remove it in the ER or at the scene of the accident.
In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and CT scan shows an underlying linear skull fracture. He is neurologically intact and gives no history of having lost consciousness.
The rule in skull fractures is that if they are closed (no overlying wound) and asymptomatic, they are left alone. If they are open (like this one), the laceration has to be cleaned and closed, but if not comminuted or depressed, it can be done in the ER.
In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and CT scan shows an underlying comminuted, depressed skull fracture. He is neurologically intact and gives no history of having lost consciousness.
This one goes to the OR for cleaning and repair, and possible craniotomy.
A pedestrian is hit by a car. When brought to the ER he has minor bruises and lacerations but is otherwise quite well, with a completely normal neurologic exam. However, the ambulance crew reports that he was unconscious at the site, and although he woke up during the ambulance ride and is now completely lucid, he does not remember how the accident happened.
Anyone who has been hit over the head and has become unconscious gets a computed tomography (CT) scan, looking for intracranial hematomas. If the CT scan and the neurologic examination are normal, he can go home—provided his family is willing to wake him up frequently over the next 24 hours to make sure he is not going into coma.
I. A pedestrian is hit by a car. He arrives in the ER in coma. He has ecchymosis around both eyes (raccoon eyes).
II. A pedestrian is hit by a car. He arrives in the ER in coma. He has clear fluid dripping out of his nose.
III. A pedestrian is hit by a car. He arrives in the ER in coma. He has clear fluid dripping from the ear.
IV. A pedestrian is hit by a car. He arrives in the ER in coma. He has ecchymosis behind the ear.
Basal skull fracture—and because the physical findings are so characteristic, they may be found as diagnostic options in exam questions of the long-listmatch- with-the-diagnosis type. They will all get a CT scan because the patient is in a coma. The scan will show the fractures, but nothing will actually be done about them. Typically, the leak of cerebrospinal fluid (CSF) will stop by itself, and although there is a higher risk of meningitis, prophylactic antibiotics have not proven to be of use. The CT scan should be extended to include the neck because the most important feature of these four vignettes is that the patients sustained significant trauma to the head and thus are at risk for lesions of the cervical spine.
A 14-year-old boy is hit over the side of the head with a baseball bat. He loses consciousness for a few minutes, but he recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated. There are signs of contralateral hemiparesis.
What is it? Acute epidural hematoma (90% likely to be right side).
Diagnosis. CT scan, which will show a lens-shaped hematoma and deviation of the midline structures to the opposite side.
Management. Emergency surgical decompression (craniotomy). Good prognosis if treated, fatal within hours if it is not.
A 32-year-old man is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride, and arrives at the ER in deep coma with a fixed, dilated right pupil and contralateral hemiparesis.
What is it? Could be acute epidural hematoma, but acute subdural is better bet. (Big-time trauma, sicker patient.)
Diagnosis. CT scan will show semilunar, crescent-shaped hematoma. Given the lateralizing signs, it will also show deviation of the midline structures to the opposite side. Be sure to check the cervical spine also!
Management. Emergency craniotomy. Evacuation of the clot often leads to significant improvement, particularly when the brain is being pushed to the side; but ultimate prognosis is poor because of accompanying parenchymal injury.
A man involved in a high-speed, head-on automobile collision is in coma. He has never had any lateralizing signs, and CT scan shows a small crescentshaped hematoma, but there is no deviation of the midline structures.
Another subdural hematoma, but without lateralizing signs and evidence of displacement of the midline structures, surgery has little to offer. Management will probably be directed at controlling ICP, as detailed in the next vignette.
A patient involved in a head-on, high-speed automobile collision arrives in the ER in deep coma, with bilateral fixed dilated pupils. CT scan of the head shows diffuse blurring of the gray-white mass interface and multiple small punctate hemorrhages. There is no single large hematoma or displacement of the midline structures.
The CT findings are classic for diffuse axonal injury. Prognosis is terrible, and surgery cannot help. Therapy will be directed at preventing further injury from increased ICP. Probably ICP monitoring will be in order. First-line measures to lower ICP include head elevation, hyperventilation, and avoidance of fluid overload. Mannitol and furosemide are next in line. Do not
overdo the treatment. Lowering ICP is not the ultimate goal; preserving brain perfusion is. Thus, diuretics that lead to systemic hypotension, or measures that produce excessive cerebral vasoconstriction may be counterproductive. Hyperventilation is indicated when there are clinical signs of herniation, and the goal is a PCO2 of 35. Lowering oxygen demand may also help.
Sedation has been used for that purpose, and hypothermia is currently advocated for the same
reason.
A 77-year-old man becomes “senile” over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.
What is it? Chronic subdural hematoma (venous bleeding, size 7 brain in size 8 skull).
Diagnosis. CT scan.
Management. Surgical decompression (craniotomy). Spectacular improvement expected
A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma with fixed, dilated pupils. He has multiple other injuries, including fractures of the extremities. His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What kind of intracranial bleeding is responsible for the low blood pressure (BP) and high pulse rate?
I trust you remember this very same vignette from the review of shock. Shock does not result from intracranial bleeding (not enough room in the head for sufficient blood loss to cause shock). Look for answer of significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures).
A man has been shot in the neck and his blood pressure is rapidly deteriorating.
Not much detail, but the point of this abbreviated vignette is that penetrating wounds anywhere in the neck need immediate surgical exploration if the patient is unstable (i.e., if vital signs are deteriorating).
A 42-year-old man is shot once with a .22-caliber revolver. The entrance wound is in the anterior left side of the neck, at the level of the thyroid cartilage. X-rays
show that the bullet is embedded in the right scalene muscle. He is spitting and coughing blood and has an expanding hematoma under the entrance wound. His blood pressure responded promptly to fluid administration, and he has remained stable.
A clear-cut case of a penetrating wound in the middle of the neck (zone II) that has alarming symptoms and therefore follows the rule (rather than the exception) for all penetrating injuries: immediate surgical exploration is required. This is true even though he is stable. The middle of the neck is packed with structures that should not have holes in them.
A young man is shot in the upper part of the neck. Evaluation of the entrance and exit wounds indicates that the trajectory is all above the level of the angle of the mandible. A steady trickle of blood flows from both wounds, and does not seem to respond to local pressure. The patient is drunk and combative but seems to be otherwise stable.
Now we are getting into the exceptions. In this very high level of the neck there is no trachea or esophagus to worry about, but only pharynx—injuries of which are inconsequential. Vascular injuries are the only potential problem, but getting to them surgically is not easy. Thus angiography is a better choice, both for diagnosis and potentially for embolization.
A young man suffers a gunshot wound to the base of his neck. The entrance and exit wounds are above the clavicles but below the cricoid cartilage. He is hemodynamically stable.
This is another part of the neck (or the thoracic outlet if you prefer) that is crammed with vital structures that should be promptly repaired if they are injured. But precise preoperative diagnosis would help plan the incision and surgical approach. If the patient is stable, the standard workup includes angiography, soluble-contrast esophagogram (followed by barium if negative), esophagoscopy, and bronchoscopy.
In the course of a bar fight, a young man is stabbed once in the neck. The entrance wound is in front of the sternomastoid muscle on the right, at the
level of the thyroid cartilage. The patient is completely asymptomatic, and his vital signs are completely normal.
In stab wounds to the upper and middle zones of the neck, completely asymptomatic patients can be closely observed but investigate if symptoms arise.
A patient who was the unbelted right front-seat passenger in a car flies through the windshield when the car crashes into a telephone pole at 30 miles an hour. He arrives in the ER strapped to a headboard and with sandbags on both sides of the neck. He has multiple facial lacerations but is otherwise stable. Examination of the neck reveals persistent pain and tenderness to palpation over the posterior midline of the neck. Neurologic examination is normal.
Every patient with head injuries from blunt trauma is a candidate for cervical spine injury. The paramedics transport everyone as if they had such injury. Neurologic deficits provide a clear answer (more about those later), but in the patient who arrives neurologically intact, we don’t want to make the diagnosis by allowing neurologic deficits to develop. Persistent local pain over the suspected area should trigger radiologic evaluation, which is best done with a CT scan of the neck.
An 18-year-old street fighter gets stabbed in the back, just to the right side of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side.
What is it? Probably no one in real life will have such a neat, clear-cut syndrome, but for purposes of examination vignettes this is a classic spinal cord hemisection, better known as Brown- Séquard syndrome.
A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature
sensation on both sides distal to the injury, while showing preservation of vibratory sense and position.
What is it? Anterior cord syndrome.
An elderly man is involved in a rear-end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain on both upper extremities while maintaining good motor function in his legs.
What is it? Central cord syndrome.
Management for cases 21–23: Start with the precise diagnosis. CT scans are good to look at the cervical bones. To look at the cord, magnetic resonance imaging (MRI) is better. Beyond that, I doubt that the long and complicated management of spinal cord injuries will be tested on the examination.
A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. Chest x-ray confirms
the presence of a rib fracture, with no other abnormal findings.
A plain rib fracture is the most common chest injury. It is bothersome but trivial in most people, but it can be hazardous in the elderly (splinting and hypoventilation leading to pneumonia). The key to treatment is local pain relief, best achieved by nerve block and epidural catheter. Beware of the wrong answers that call for strapping or binding.
A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds on the right, which is hyperresonant to percussion.
What is it? Plain pneumothorax.
Diagnosis. There is time to get a chest x-ray if the option is offered.
Management. Chest tube to underwater seal and suction. If given an option for location, at the fifth intercostal space, mid-axillary line.
A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. The base of the right chest has no breath sounds and is dull to percussion. He has faint distant breath sounds at the
apex.
What is it? Sounds more like hemothorax.
Diagnosis. Chest x-ray. If confirmed, treatment is chest tube on the right, at the base of the pleural cavity. If contaminated blood is allowed to stay there, it will develop an empyema with potentially a lot of future
problems.
A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds at the right base, and only faint distant breath sounds at the apex. The right base is dull to percussion. Chest x-ray confirms the presence of a hemothorax. A chest tube placed at the right pleural base recovers 120 ml of blood and drains another 20 ml in the next hour.
Management. The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure) and stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterward.