Neck Trauma
Dr. McMurray

Zone 1: Clavicles to cricoid

• Highest mortality rate due to proximity to mediastinal structures

Zone 2: Cricoid cartilage to angle of mandible

• Most commonly injured
• Classically, zone II injuries undergo surgical exploration, zone I and III undergo further evaluation

Zone 3: angle of mandible to base of skull

Penetrating trauma:

• Has to penetrate the platysma which demarcates superficial from deep wounds
• Most common cause of immediate death is involvement of carotid artery

Hard signs of vascular injury:

• Hypotension
• Arterial bleeding
• Rapidly expanding hematoma
• Deficits (pulse/neuro)
• (bruit/thrill)

Hard signs of aerodigestive trauma:

Air bubbling, massive hemoptysis, respiratory distress

Soft signs

subQ air

dysphonia

dysphagia

Blunt Trauma

• Blunt vascular injury have up to 60% risk of stroke; if no operative intervention, consider ASA/Plavix/heparin etc

Denver Screening Criteria

• Used to screen for vertebral and carotid artery dissection and/or injury after blunt head/neck trauma
• CTA if 1 or more criteria present
• Reduces number of missed injuries to <5%

Strangulation

• Most common cause of death is neck vessel occlusion rather than airway obstruction
• Also can have laryngotracheal fx, C-spine injury
• If dyspnea, dysphonia, odynophagia, etc need laryngobronchoscopy
  
  

Ophthalmic Trauma
Dr. Nelson

Corneal abrasions:

• Richly innervated = very painful
• Short healing time 24-48 hours
• Common causes: mechanical trauma, foreign body, contact lenses, flash burns
• Clinical features: foreign body/gritty sensation, injection, tearing, relief with topical anesthetic, can also have photophobia and vision change
• Workup and diagnosis: eyelid exam with eversion, fluorescein exam looking for uptake
• Consider corneal ulceration in contact lens wearers
• Treatment: Removal of foreign body, PO/topical NSAIDs, abx (erythromycin in general population, fluoroquinolone drops in contact wearers for pseudomonal coverage)
• Ophtho follow up

Open globe:

• Full thickness disruption of sclera or cornea
• Clinical pictures: pain, decreased visual acuity, teardrop shaped pupil
• AVOID pressure on the eye = do NOT perform tonometry
• May have positive Seidel’s test on fluorescein exam
• CT orbit if concern for foreign body
• Management: urgent ophtho consult for repair, cover eye, elevate HOB, bed rest, tdap, abx
  • If no foreign body, IV fluoroquinolone
  • If foreign body, IV vanc+ceftaz

Eyelid Lacerations:

• Ophtho consult for repair:
  • Lid margin
  • Within 6-8mm of medial canthus
  • Lacrimal duct/sac
  • Inner surface of lid
  • If ptosis is present
  • Tarsal plate or levator palpebrae involvement
• Full thickness (through and through): high risk for ocular injury, eval for corneal lacs and globe rupture
• Partial thickness: most simple horizontal lacs can be repaired by ED physician, ends of sutures should be kept away from cornea to prevent further abrasion
• Lid margin lacerations: very small <1mm do not need repair and will heal spontaneously, if larger consult ophtho for repair
  
  

PEM Lecture-Abdominal Trauma:
Dr. Elmore

• Trauma is the most common cause of death in children from 1-18 years old in the US
• Blunt abd trauma accounts for more than 90% of childhood injuries
• It is the most unrecognized cause of fatal injuries
• Children are at greater risk due to immature skeleton and they have higher abd organ to body mass ratio
• Children are able to compensate in the face of significant blood loss
• Clinical prediction rule may rule out intraabdominal injury in blunt trauma
  • No sign of abd wall injury
  • No TTP
  • No evidence thoracic wall trauma
  • No abdominal pain
  • No decrased bowel sounds
  • No vomiting
• HDS but concern for intraabdominal injury if:
  • Hct<30
  • UA>5 RBCs
  • AST>200,ALT>125
  • Elevated lipase
  • Low systolic BP
  • Femur fx
• Spleen most commonly injured intraabdominal organ, liver second
• Pancreatic injury = classic “handlebar” injury from bike accident (also consider duodenal injury/hematoma with this mechanism)
• Hollow viscera injuries are rare, but most common causes are lap belt injuries, peds vs. auto, NAT (rapid acceleration/deceleration)
• As many as 50% of children with Chance fx have intra-abdominal injury such as duo perf, mesenteric disruption, transection of small bowel, panc injury, bladder rupture
• TEN-4 rule for NAT
  • Bruising on torso, ears, or neck of child >4 years old
  • Any bruising in an infant 4 months old or less
    
    

Small Group: Abdominal Trauma
Dr. Harmon

•   Indications for immediate lap in penetrating abdominal trauma:
  • Peritonitis (rigid abdominal wall, rebound tenderness)
  • Hemodynamic instability
  • Evisceration of abdominal contents
  • Hematemesis or gross blood per rectum
• Literature varies widely on sensitivity of CT for bowel/mesenteric injuries
• CT findings that may indicate bowel injury:
  • Stranding, bowel wall thickening, pneumoperitoneum
• Findings concerning for diaphragm injury:
  • Elevated/blurred L hemidiaphragm, bowel sounds in chest, gastric bubble/air fluid level in chest, mediastinal shift away from affected side
  • Gold standard for diagnosis of diaphragm injury is exploration in OR; cannot be ruled out by CT or CXR

 Traumacology
Dr. Senn, PharmD

• Triad of trauma: hypothermia, coagulopathy, acidosis
  
  
• TXA for trauma patients:
  • CRASH-2 trial compared TXA vs. placebo
    • In hospital mortality within 4 weeks of injury
    • Reduction in all cause mortality, greatest benefit SBP<75 and if given within 3 hours of initial injury
  • MATTERS trial 1g TXA given, greater impact on those requiring MTP
• Take-home points for TXA: consider using in adult trauma patients with severe hemorrhagic shock (SBP<90), ideally <3h from injury
  • Dosing: 1g over 10 min followed by 1g over 8h
• Trauma patients, hypocalcemia, and blood transfusion
  • Twice mortality for those with iCal <0.9
  • Calcium plays vital role in coagulopathy
  • Consider administration 1g CaCl or 3g Ca gluconate when giving 3-4 PRBCs/FFP