Month: October 2016

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Cardiac tamponade. Aortic Dissection. Blunt cardiac injury.

Cardiac Tamponade

• Blood fills pericardial sac
  • Increasing pressure on myocardium -> Decreased preload
  • Decreased preload -> Hypotension -> Death
• Clinical exam shows Beck’s Triad
  • Hypotension
  • Muffled heart sounds
  • Jugular venous distension (JVD)
• Diagnosed during FAST exam (subxiphoid view)
• Treat with pericardiocentesis
  • Bedside thoracotomy if patient loses pulse

Aortic Dissection/Rupture/Tear

• Common with rapid deceleration injuries
• Most commonly occurs at ligamentum arteriosum
  • Small ligament that attaches arch of aorta to pulmonary artery
  • Remnant of the ductus arteriosus
• Obtain CTA of the chest if…
  • Widened mediastinum on chest x-ray
  • Unequal pulses
  • Concerning mechanism of injury
• Requires emergent repair

Blunt Cardiac Injury

• Contusion to the myocardium can cause arrhythmia/death
  • Place patient on cardiac monitor
  • Consider EKG/troponin
• Commotio Cordis
  • Blunt impact to chest resulting in ventricular fibrillation

Additional Reading

• Blunt Cardiac Injury (American Association for the Surgery of Trauma)
• FAST Exam (SAEM)

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Step 1: Perform ATLS Primary Survey (B- Breathing)

• Signs of respiratory distress/injury
  • Shortness of breath
  • Hypoxemia
  • Tracheal deviation
  • Diminished breath sounds

Step 2: Consider Performing Bedside Tube Thoracostomy

• Insert at 5th intercostal space just anterior to mid-axillary line

Step 3: Imaging

• Start with portable bedside chest x-ray
• Pneumothorax can also be diagnosed by thoracic ultrasound

Step 4: Consider the 3 Critical Diagnoses

• Tension pneumothorax
  • Pressure builds up between chest wall and lung
  • Eventually decreases cardiac preload -> Hypotension/Death
  • Treatment
    • Needle decompression
    • Tube thoracostomy
• Open pneumothorax
  • Lung unable to expand during inspiration
  • Treatment
    • 3-sided occlusive dressing over open (“sucking”) chest wound
    • Tube thoracostomy
• Hemothorax
  • Chest cavity fills with blood
  • Eventual decreases cardiac preload -> Hypotension/Death
  • Treat with tube thoracostomy

Step 5: Consider the 3 Other Common Diagnoses

• Rib fractures
  • Diagnose with chest x-ray
  • Treatment
    • Pain control
    • Incentive spirometry
• Small pneumothorax
  • Worsens with positive pressure ventilation (intubation, BiPAP)
  • Treatment
    • Supplemental oxygen
    • Supportive care
• Pulmonary contusion
  • Supportive care

Additional Reading

• Round 12 – Difficulty Breathing (EM Clerkship)
• Chest Tube Thoracotomy Demonstration (YouTube)

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The hardest question… Should you get a CTA?

Blunt Trauma of Neck

• Obtain CTA if…
  • Patient has neurologic deficit
    • Numbness
    • Weakness
    • Visual changes
  • Patient sustained forceful impact to the neck
  • Patient has fracture
    • Basilar skull
    • Facial bones
    • Cervical spine

Penetrating Trauma of the Neck

• Go to OR if patient is unstable
• Go to OR if patient has HARD signs
  • HARD Bruit Mnemonic
    • Hemoptysis/Hematemesis/Hypotension
    • Arterial bleeding
    • Rapidly expanding hematoma
    • Deficit (neurologic/pulse)
    • Bruit
• Otherwise obtain CTA of the neck

Additional Reading

• Neck Trauma: A Practice Update (emDOCs)

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Step 1: Protect the Spine

• Apply cervical collar

Step 2: Apply NEXUS Criteria

• Use the “SPINE” mnemonic
  • Spinal midline tenderness
  • Painful distracting injury
  • Intoxication
  • Neurologic deficit
  • Encephalopathy

Step 3: If Patient Has None of the NEXUS Criteria… You Are Done!

Step 4: If Patient Has Positive NEXUS Criteria…

• Obtain CT scan of the cervical scan without contrast

Step 5: Clear the C-Spine

• If CT scan negative -> Have patient turn head 45 degrees to right and left
  • If patient has no limitation and no paresthesias or neurologic deficit…
    • Remove collar
  • If still concerned for spinal injury despite normal CT
    • Keep collar on and have patient follow up in clinic for reexam

Unstable Cervical Spine Fractures

• Mnemonic: Jefferson Bit Off a Hangmans Tit
  • Jefferson fracture
  • Bilateral facet dislocation
  • Odontoid fracture
  • Atlantooccipital dislocation
  • Hangman’s fracture
  • Teardrop fracture

Additional Reading

• NEXUS Criterial for C-Spine Imaging (MDCalc)
• Unstable Spine Fractures (WikEM)