the case.
A 2 year old infant is bought to your ED with a painful right hand. She claims to be have been bitten by the family dog 2 days earlier… [Read more…]
pulling apart cases from the ED...
the case.
A 2 year old infant is bought to your ED with a painful right hand. She claims to be have been bitten by the family dog 2 days earlier… [Read more…]
the case.
You receive a BAT call about a 31 year-old male who has come off his bicycle after running into a stationary car at ~30 km/hour. Bystanders report that he was thrown 3-5m and had a loss of consciousness of ~3 minutes without witnessed seizure activity. [Read more…]
A 24 year old male rugby player presents to your ED with a severely painful, swollen left hand which occurred during a tackle and subsequent ruck.
These are his x-rays….
the case.
a 19 year old female arrives to your resuscitation bay following a high-speed rollover MVA where she was the restrained passenger.
A joint decision with the Trauma surgeons is made; and we head to radiology for a pan-CT. This revealed the following…
httpv://www.youtube.com/watch?v=9B1YMOr9LK0&feature=youtu.be
What does the scan demonstrate…?
A flexion-distraction injury of the lumbar spine.
It represents failure of both the posterior and middle spinal columns under tension forces generated by flexion and distraction (from a fulcrum focus anterior to the vertebral body).
This is an unstable fracture involving all three spinal columns.
There is significant distractive disruption of middle & posterior ligamentous structures (50% of cases).
It is unusual, in that the fracture line extends through the spinous process, pedicle and into the vertebral body.
** Subtype of Flexion-Distraction Injuries – Image taken from Denis (1983) **
Most commonly associated with seat-belt injuries (especially isolated lap belts only).
This is often misdiagnosed as an anterior compression fracture.
Why is this injury so significant…?
Chance fractures are strongly associated with intraabdominal injuries. These result from rapid deceleration of intraabdominal contents against the lap belt, or compression against the anterior spine. There is also subsequent increased intraluminal pressure in hollow viscus structures.
CT scan is the preferred initial diagnostic modality of choice in the haemodynamically stable patient with a Chance fracture. It is however important to recognise its limitations particularly in the diagnosis of small bowel injury.
Remember to treat this injury like any other unstable spinal injury.
Our patient remained haemodynamically stable. Her MRI spine showed no evidence of epidural haematoma, canal or foramina narrowing. There was however ligamentous injury posteriorly, mainly at L1-2.
Whilst her mandible was repaired on Day 2, her splenic injury was managed conservatively.
This was her final operative repair prior to discharge home….
The Case.
A 36 year old male presents through your sub-acute area with increasing facial pain & swelling. He reports a simple trip and fall 18 hours earlier (no alcohol on board, recalls all events), where his right cheek struck a concrete step. He had no LOC at the time, and has no historical features concerning for intracranial injury.
He is worried today as the swelling ‘just keeps getting worse’.
On examination he has obvious marked right zygomatic/maxillary swelling and ecchymoses. His cranial nerves are ok (particularly extra-occular movements and facial sensation). When you palpate his facial bones, for find something unexpected which leads you to expediting his CT scan….
What has happened here ? What other injuries may have been sustained ??
Interpretation & Progress.
This CT demonstrates a comminuted, depressed maxillary fracture involving the orbital floor and lateral orbital wall (a ‘blow-out’ type fracture), with extension into the maxillary alveolar process.
The most striking feature of this CT-series is the abundance of subcutaneous emphysema, and of particular concern to me was the extent to which it had traveled (to contralateral carotid sheath, SCM & masseter, submandibular space & of most concern to me, the retropharyngeal space at the level of the epiglottis).
Whilst a bony injury of this magnitude requires little further ED work-up & can usually be referred to your Plastics/Maxillofacial surgeons as an outpatient, the amount of soft-tissue air in this case made us reluctant to simply discharge him home.
Subcutaneous emphysema in the setting of facial and neck trauma raises the suspicion & should prompt the consideration of an aero-digestive injury. Our patient in this case had a single isolated blow to the right cheek & no evidence of anterior neck injury (and gave excellent recollection of the events). He had no dysphagia, dysphonia or neck pain, but did report a recent runny nose. Regardless, we elected to pursue this further by asking our ENT colleagues to review him.
In short, he was admitted for observation & commenced on IV antibiotics. The ENT registrar performed a nasendoscopy in the ED revealing a macroscopically normal airway to the level of the cords. He was discharged home 48 hours later with no further sequelae from his injury.
What to know about Orbital Fractures…
Orbital Fractures.
The most common simple fracture of the orbit is the ‘blow-out’ fracture of the orbital floor.
Assessment:
* Bony fragments & orbital contents can sag/herniate into the maxillary sinus.
* Enophthalmos vs Exophthalmos (more likely to occur with medial wall involvement)
* Assess for diplopia & EOM (particular inferior rectus function)
* Pic courtesy of Otolaryngology Houston
* Pic courtesy of Zygomatic Complex & Nasal Injury
* Retrobulbar haematomas (or malignant orbital emphysema) can create an ocular compartment syndrome leading to blindness from acute ischaemic optic neuropathy. (Suggested by exophthalmos, reduced visual acuity & increased IOPs).
Management.
Lastly; avoid sneezing and don’t blow your nose !! This can force air from the sinuses into soft tissues...
As it turns out, our man had a simple case of man-flu just prior to his injury and in the 12 hours prior to his ED arrival had been vigorously blowing his nose in attempt to clear his nostrils !!
The Case.
A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.
No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.
Here are his initial xrays….
As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….
httpv://www.youtube.com/watch?v=P8jIf50wnQw&feature=youtu.be
He went straight to theatre from radiology, and unfortunately underwent an above-knee amputation.
Whilst the decision making process was rather straight forward in this case, it did lead me to revisit the ED-based evaluation of suspected peripheral vascular injury….
Peripheral Vascular Injury – Tell me more…
Typically these injuries are divided into blunt vs penetrating, however they generally result in a similar spectrum of vascular injuries (including laceration, transection, entrapment, avulsion, intimal tears/flaps, pseudoaneurysm, AV-fistulas, thrombosis & spasm).
Detection & treatment of vascular injuries must take place within the context of overall resuscitation of a patient. This also includes the control of active bleeding.
The assessment of peripheral vascular injury can be divided into three categories;
Hard Findings of Vascular Injury.
The incidence of arterial injury is > 90% if any of these are present !! Surgical exploration is required.
Soft Findings of Vascular Injury.
Up to 35% of patients with soft-signs will have positive angiographic findings !!
High-Risk Injuries.
Meticulous examination is required to look for the above hard & soft signs. Surprisingly, these are relatively dependable (Sensitivity 92%, Specificity 95%).
Diagnostic investigations.
These must be tailored to the patient & their injury, and should never delay a definitive treatment to an obvious arterial injury (especially if the clock is approaching the all-important 6 hour warm ischaemia time).
Modalities include plain radiography, pulse-oximetry, hand-held Doppler, ultrasound (including colour-flow and duplex), CT & MRI. CT-angiography is now the most commonly used primary diagnostic study for the evaluation of penetrating lower extremity vascular injury.
The investigation that I wanted to focus on is Arterial-Pressure Index, as I feel it can be easily done at the bedside as an extension to your physical examination.
Caution w/ API: Limited usefulness in deep arteries (profunda femoris, profunda brachii & peroneal arteries) which do not produce palpable pulses & with shot-gun wounds which often cause multiple small arterial injuries.
Summary.
References.