September 17, 2015
Neck Trauma

Case Scenario 1
It's a busy Friday night in your community ED. You get a tele call about a stab wound victim on his way in from a bar fight. Vitals are presently stable. Victim has been stabbed in the neck with a box cutter. EMS is holding pressure at the neck. Primary survey on arrival, the patient is awake, alert and speaking. He has symmetric breath sounds and pulses are intact in both extremities. You notice a 1 inch stab wound to the left lateral aspect of the neck with significant bleeding. When pressure is removed, you notice some air bubbles and palpation of the neck immediately adjacent reveals crepitus.
PGY-1
  1. Anatomically what are the three zones of the neck? Describe the boundaries of each.
  2. What structures are included in each zone?
  3. Which zone is the most commonly injured in penetrating neck trauma?
  4. Besides bleeding from SW site, what other kinds of signs and symptoms can be seen in penetrating trauma of the neck?
  5. What is the incidence of penetrating injuries to the neck? What is the mortality associated with same?
Readings
PGY-2
  1. With respect to SW of the neck, what are the indications to go to the OR immediately?
  2. What are the indications to observe the patient in a monitored setting? Which patients can be potentially discharged from the ED?
  3. Which patients need imaging? What kind of imaging is typically recommended?
  4. What are the indications to intubate patients with penetrating neck wounds?
  5. If an obvious injury is noted to the carotid or the jugular, what is a temporizing measure until definitive care?
Readings
PGY-3
  1. If this patient had a GSW to the neck, how would the management differ?
  2. What are the most commonly missed injuries in penetrating neck trauma?
  3. If the patient in the case above developed sudden acute respiratory and shock like symptoms, what diagnosis must be considered? What is the treatment? How can it be prevented?
  4. What is direct tracheal intubation and when do you perform it?
Readings
Case Scenario 2
Shortly after dispatching the patient in the prior case to the nearest Trauma center, you get a 45 year old male patient in your ED complaining of neck pain. He reports that two days ago he was in a moderate MVA, airbags deployed. He got hit in the neck. He was checked out at another hospital and they discharged him as he had no acute injuries. The patient initially thought that his neck was just bruised and that he would get better, but he has been feeling dizzy with persistent neck pain since that time. On exam he appears anxious, vitals HR 110, BP 100/67, RR 26, O2 92%.
PGY-1
  1. What are the major differences in pathology between penetrating and blunt neck trauma? Discuss some of the mechanisms of injury.
  2. In the above case, what would you look for on the clinical exam?
Readings
PGY-2
  1. How is pediatric neck anatomy different from adult neck anatomy with respect to laryngo-bronchial trauma?
  2. What are some common delayed injuries seen with blunt neck trauma?
  3. In patients with massive blunt trauma of the neck with visibly distorted anatomy, how would you secure the airway? What is the modality of choice?
  4. In what two specific blunt neck injuries is RSI contraindicated?
Readings
PGY-3
  1. In which patients is cricothyrotomy relatively contraindicated?
  2. What procedures can be performed in lieu of a cricothyrotomy as a temporizing measure?
Readings
Case Scenario 3
It's about one hour to the end of your shift and EMS brings around a hysterical intoxicated female who was found by the roadside. She is crying and inconsolable and paramedics report possibility of suicide attempt, but they are not certain of how. The patient is awake, alert, crying and not answering any questions. On exam she has a HR 110, BP 110/76, RR 24, O2 95%, T 99.1. She has ligature marks around the neck. She also has some bruises to the forearms and face. On closer inspection she has some petechiae above the ligature marks. Lungs have coarse breath sounds. She has alcohol and tobacco on her breath.
PGY-1
With respect to the patient above, what is next course of action?
What is the pathophysiology underlying strangulation injuries?
Readings
PGY-2
After a psych workup has been sent, your RN comes to you and asks to order medications to sedate the above patient as she is exhibiting signs of extreme anxiety and keeps reporting that she can't breath.
  1. What kind of pulmonary complications can be seen post strangulation and what is the mechanism of action?
Readings
PGY-3
  1. What are some injuries that can be seen in strangulation and non-judicial hangings?
  2. Clinically what three groups can these patients be divided into?
Readings