Snapshot A 27-year-old male is brought in to the ED after being found down in front of his apartment. The neighbors report that the patient was a stabbing victim, and a small knife was found on the left neck by EMS and left in place. En route, the patient’s blood pressure is 91/53 mmHg, pulse is 110/min, respirations are 21/min, and oxygen saturation is 95% on room air with GCS of 15. On exam, there is a small knife on the lateral left neck above the sternal notch with a large hematoma that feels pulsatile. There are decreased breath sounds on the left apical lung. There are also multiple stab wounds and lacerations on his back. Introduction Neck trauma can be described neck zones zone I: base of neck (thoracic inlet to cricoid cartilage) zone II: midportion of neck (cricoid to angle of mandible) zone III: superior aspect of neck Mechanism of injury can determine zones and layers of neck involved Presentation Airway injury larynx history: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma triad: hoarseness, subcutaneous emphysema, palpable fracture crepitus other symptoms: hemoptysis, dyspnea, dysphonia trachea/bronchus history: deceleration, penetration, increased intrathoracic pressure symptoms: dyspnea, hemoptysis exam: subcutaneous emphysema, Hamman's sign (crunching sound synchronized to heart beat) Pharynx/esophageal injury hematemesis, difficulty swallowing, saliva exiting out of the wound, pneumomediastinum Vascular injury most common injury with penetrating neck trauma hematoma, absent carotid pulse, bruit, shock Nerve injury vagus, spinal accessory, hypoglossal, phrenic nerves are at risk symptoms associated with the specific nerve damaged Management General approach patient should be transported to a trauma center. Meanwhile, immobilize neck to prevent further injury primary survey if penetrating neck trauma present, do NOT: clamp structures (high risk of nerve damage) probe with finger insert nasogastric tube (risk of perforation/bleeding) remove weapon/impaled object in the ED presence of hemodynamic instability or “hard signs” of tissue injury prompt surgical intervention hard signs include vascular injury pulsatile bleeding, expanding hematoma, bruit, signs of cerebral ischemia, absent carotid pulse aerodigestive injury bubbling from the wound, hoarseness, stridor, subcutaneous emphysema, respiratory distress secondary survey imaging CXR and CT scan asymptomatic patients may have time for CT angiogram, esophagoscopy or bronchoscopy to fully characterize extent of injury and dictate further management
QUESTIONS 1 of 3 1 2 3 Previous Next (M2.ET.17.4685) A 27 year-old-male presents to the Emergency Room as a code trauma after being shot in the neck. En route, the patient’s blood pressure is 127/73 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 100% on room air with GCS of 15. On physical exam, the patient is in no acute distress; however, there is an obvious entry point with oozing blood near the left lateral neck above the cricoid cartilage with a small hematoma that is non-pulsatile and stable since arrival. The rest of the physical exam is unremarkable. Rapid hemoglobin returns back at 14.1 g/dL. After initial resuscitation, what is the next best step in management? QID: 107360 Type & Select Correct Answer 1 MRI 0% (0/15) 2 Plain radiography films 27% (4/15) 3 Conventional angiography 0% (0/15) 4 CT angiography 73% (11/15) 5 Bedside neck exploration 0% (0/15) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.ET.17.4686) A 45-year-old female presents to the emergency room as a trauma after a motor vehicle accident. The patient was a restrained passenger who collided with a drunk driver traveling approximately 45 mph. Upon impact, the passenger was able to extricate herself from the crushed car and was sitting on the ground at the scene of the accident. Her vitals are all stable. On physical exam, she is alert and oriented, speaking in complete sentences with a GCS of 15. She has a cervical spine collar in place and endorses exquisite cervical spine tenderness on palpation. Aside from her superficial abrasions on her right lower extremity, the rest of her examination including FAST exam is normal. Rapid hemoglobin testing is within normal limits. What is the next best step in management of this trauma patient? QID: 107375 Type & Select Correct Answer 1 CT cervical spine 82% (14/17) 2 Remove the patient’s cervical collar immediately 0% (0/17) 3 Discharge home and start physical therapy 6% (1/17) 4 Consult neurosurgery immediately 6% (1/17) 5 Initiate rapid sequence intubation. 0% (0/17) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M2.ET.14.52) A 21-year-old man presents to the emergency department after sustaining a stab wound to the neck at a local farmer's market. The patient is otherwise healthy and is complaining of pain. The patient is able to offer the history himself. His temperature is 97.6°F (36.4°C), blood pressure is 120/84 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam demonstrates a 3 cm laceration 1 cm inferior to the mastoid process on the right side. The patient's breath sounds are clear and he is protecting his airway. No stridor or difficulty breathing is noted. Which of the following is the most appropriate next step in the management of this patient? QID: 106350 Type & Select Correct Answer 1 Arteriography 14% (3/22) 2 CT angiogram 32% (7/22) 3 Intubation 32% (7/22) 4 Observation and blood pressure monitoring 23% (5/22) 5 Surgical exploration 0% (0/22) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic