The Counting&The Flock

medinuggets:

Case 9 | Pain in the neck…
Nigel, a 48 year old male was sat on a bench with some friends when an old acquaintance called Edward approached him. Edward had a pair of scissors taped to his right hand and preceded to try to stab Nigel, landing a blow to his neck. One of Nigel’s friends managed to control Edward by punching him in the head and knocking him to the floor, after which he got up and disappeared into the woods nearby.
Nigel had sustained several superficial lacerations to his torso and a wound to the left side of his neck. He reported air coming out of the wound in his neck and has been complaining of a painful swallow and a newly hoarse voice.
On examination he was alert and orientated with no signs of airway compromise or bleeding. He was warm and well perfused. HR was 77, BP 132/88, RR 16 and Sats 96% on RA. There was a penetrating laceration anterior to the mid belly of the anterior sternocleidomastoid.
CT Angio of his neck showed marked subcutaneous emphysema but no vascular/aero-oesophageal injury. It’s possible the air was coming from the wound itself. Nonetheless he was promptly transferred to the tertiary referral centre. He is still in hospital being managed conservatively

DISCUSSION:
Penetrating neck trauma… Traditionally we divide the neck into the anterior and posterior triangles. In terms of penetrating neck trauma we can divide the neck differently – into 3 zones, separated by the cricoid cartilage and the angle of the mandible.
Zone III 
Treat as cranial injuries
Carotids, pharynx, spinal cord
Vascular control difficult
 ———————————————>Angle of mandible 
Zone II
Oesophagus, trachea, larynx
Jugular veins, Carotids Spinal cord
Safest for exploration
 ———————————————>Cricoid cartilage 
Zone I 
Carotids, oesophagus, trachea
Lung, major thoracic vessels Spinal cord
Vascular control difficult
———————————————> Clavicle 
Surgical exploration is problematic in zones 1 and 3 due to difficulty in exposing the injury and gaining vascular control; thus patients with vascular injury in these zones have a higher mortality.
The platysma is the most superficial structure beneath the skin and subcutaneous tissue. If the wound penetrates this assume significant injury: DO NOT start poking your fingers inside to have a look about.
C-Spine precautions are more relevant in blunt trauma but should be considered in penetrating injury also.
Beyond this the neck is divided into tight compartments. They can tamponade bleeds which prevent blood pouring out externally…however internal extravasation of blood/air can extrinsically compress the airway. If the patient has:


- Acute respiratory distress
- Airway obstruction/tracheal shift
- Massive subcutaneous emphysema
- Expanding haematoma
- Altered level of consciousness


…then aggressively manage the airway. Get senior help for airway management EARLY. Don’t clamp bleeding vessels. Also look for hoarseness, dysphagia, vocal cord paralysis, cranial nerve palsies, apical capping on a CXR and a haemothorax.
Investigate with a CTAngio/HCTAngio. For zone 1: patients should have a laryngo/bronchoscopy and oesophago-endoscopy. Zone 3 patients should have a catheter angio; surgical exploration is fraught with difficulty and apparently not often indicated. Further investigating in Zone 2 injuries is controversial – some advocate exploration and some advocate angiography/bronchoscopy/oesophagoscopy and observation.
In Summary:


- Take it seriously, no matter how innocuous it may look
- If it goes beyond the skin and subcutaneous tissue then assume the worst
- Any suggestion of threatened airway then manage aggressively before it gets worse
- Know your zones
- CT angio
- Don’t go a-pokin’
- Transfer to definitive care


Reference: 1. Tintinelli; Tintinelli’s Emergency Medicine, 7th Ed; p1739-1741
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medinuggets:

Case 9 | Pain in the neck…

Nigel, a 48 year old male was sat on a bench with some friends when an old acquaintance called Edward approached him. Edward had a pair of scissors taped to his right hand and preceded to try to stab Nigel, landing a blow to his neck. One of Nigel’s friends managed to control Edward by punching him in the head and knocking him to the floor, after which he got up and disappeared into the woods nearby.

Nigel had sustained several superficial lacerations to his torso and a wound to the left side of his neck. He reported air coming out of the wound in his neck and has been complaining of a painful swallow and a newly hoarse voice.

On examination he was alert and orientated with no signs of airway compromise or bleeding. He was warm and well perfused. HR was 77, BP 132/88, RR 16 and Sats 96% on RA. There was a penetrating laceration anterior to the mid belly of the anterior sternocleidomastoid.

CT Angio of his neck showed marked subcutaneous emphysema but no vascular/aero-oesophageal injury. It’s possible the air was coming from the wound itself. Nonetheless he was promptly transferred to the tertiary referral centre. He is still in hospital being managed conservatively


DISCUSSION:

Penetrating neck trauma… Traditionally we divide the neck into the anterior and posterior triangles. In terms of penetrating neck trauma we can divide the neck differently – into 3 zones, separated by the cricoid cartilage and the angle of the mandible.

Zone III

Treat as cranial injuries

Carotids, pharynx, spinal cord

Vascular control difficult

———————————————>Angle of mandible

Zone II

Oesophagus, trachea, larynx

Jugular veins, Carotids Spinal cord

Safest for exploration

———————————————>Cricoid cartilage

Zone I

Carotids, oesophagus, trachea

Lung, major thoracic vessels Spinal cord

Vascular control difficult

———————————————> Clavicle

Surgical exploration is problematic in zones 1 and 3 due to difficulty in exposing the injury and gaining vascular control; thus patients with vascular injury in these zones have a higher mortality.

The platysma is the most superficial structure beneath the skin and subcutaneous tissue. If the wound penetrates this assume significant injury: DO NOT start poking your fingers inside to have a look about.

C-Spine precautions are more relevant in blunt trauma but should be considered in penetrating injury also.

Beyond this the neck is divided into tight compartments. They can tamponade bleeds which prevent blood pouring out externally…however internal extravasation of blood/air can extrinsically compress the airway. If the patient has:

- Acute respiratory distress

- Airway obstruction/tracheal shift

- Massive subcutaneous emphysema

- Expanding haematoma

- Altered level of consciousness

…then aggressively manage the airway. Get senior help for airway management EARLY. Don’t clamp bleeding vessels. Also look for hoarseness, dysphagia, vocal cord paralysis, cranial nerve palsies, apical capping on a CXR and a haemothorax.

Investigate with a CTAngio/HCTAngio. For zone 1: patients should have a laryngo/bronchoscopy and oesophago-endoscopy. Zone 3 patients should have a catheter angio; surgical exploration is fraught with difficulty and apparently not often indicated. Further investigating in Zone 2 injuries is controversial – some advocate exploration and some advocate angiography/bronchoscopy/oesophagoscopy and observation.

In Summary:

- Take it seriously, no matter how innocuous it may look

- If it goes beyond the skin and subcutaneous tissue then assume the worst

- Any suggestion of threatened airway then manage aggressively before it gets worse

- Know your zones

- CT angio

- Don’t go a-pokin’

- Transfer to definitive care

Reference: 1. Tintinelli; Tintinelli’s Emergency Medicine, 7th Ed; p1739-1741


medinuggets:

Case 6 | Achey Chest

70 year old man presents to ED at 5pm with 2 episodes of central dull chest ache over the last 24 hours that had each lasted around 1 hour. He had a background of IHD, having had a CABG 12 years ago and a stent in 2008. Pain subsided in the ED with aspirin and GTN but he had a further episode of chest ache at 3:40am in the CCU. The nurses notice a change in the rhythm and perform another ECG, when he suddenly becomes unresponsive.

Explanation to follow…

Interesting ECGs we had overnight in the ED…via www.medinuggets.com. View Larger

medinuggets:

Case 6 | Achey Chest

70 year old man presents to ED at 5pm with 2 episodes of central dull chest ache over the last 24 hours that had each lasted around 1 hour. He had a background of IHD, having had a CABG 12 years ago and a stent in 2008. Pain subsided in the ED with aspirin and GTN but he had a further episode of chest ache at 3:40am in the CCU. The nurses notice a change in the rhythm and perform another ECG, when he suddenly becomes unresponsive.

Explanation to follow…

Interesting ECGs we had overnight in the ED…via www.medinuggets.com.


Case 3 | Soft, non-tender

66 year old normally well female with a 3 day history of abdominal distension and minimal pain.  No previous surgical history. Takes occasional Mobic and Lipitor for OA and Hypercholesterolaemia respectively. On examination: looks well. Observations within normal limits. Soft, hyper-resonant, non-tender abdomen. View Larger

Case 3 | Soft, non-tender

66 year old normally well female with a 3 day history of abdominal distension and minimal pain. No previous surgical history. Takes occasional Mobic and Lipitor for OA and Hypercholesterolaemia respectively. On examination: looks well. Observations within normal limits. Soft, hyper-resonant, non-tender abdomen.


Inotropes Part 2 | Agents

Epinephrine

  • Alpha and Beta agonist
  • 2-10mcg/min = mostly Beta 1
  • >10mcg/min = mostly Alpha
  • Risks: arrhythmias, AMI, organ ischaemia

Phenylephrine

  • Alpha only, minimal cardiac effects

Norad

  • Alpha and Beta agonist
  • <2mcg/min mostly Beta
  • >3mcg/min added Alpha
  • First line for septic shock

Dopamine

  • 0.5-2mcg/kg/min = D1
  • 2-5mcg/kg/min = stimulates norad release
  • 5-10mcg/kg/min = Beta 1
  • >10mcg/kg/min Beta 1 + Alpha

Dobutamine

  • Beta 1
  • Less myocardial O2 consumption

Ellender TJ, Skinner JC. Emerg Med Clin North Am. 2008 Aug;26(3):759-86