Hay, hay…..CTA!!*

*(Warning: bad pun)

Craig Hore Intensive Care Unit Liverpool Hospital

For the city slickers…..

MIST M:

75 yr old male brought to by helicopter after getting head trapped between tractor hydraulic mechanism and hay bale lifting apparatus (approx. 4 inch gap)

Previously fit and well

I: Ü  Lateral and anterior neck injuries Ü  Head injury Ü  Facial bone injuries

Approx Injury Time: 10.40 Dispatched: 10.53 Arrive scene: 11.40 Depart: 12.08 ED: 13.04

MIST S:

Ü  BP= 140/75 HR= 63 Ü  GCS = 15 Ü  RR 25 Sats 96%

T: Ü  Fentanyl Ü  Ondansetron Ü  Sandbags and tap (not tolerating cervical neck

collar)

Approx Injury Time: 10.40 Dispatched: 10.53 Arrive scene: 11.40 Depart: 12.08 ED: 13.04

Primary Survey

Approx Injury Time: 10.40 Dispatched: 10.53 Arrive scene: 11.40 Depart: 12.08 ED: 13.04

A

Ü  Patent; no stridor

Ü  Neck - sandbags and tape in situ

Ü  Expectorating blood

B

Ü  SpO2 96%

Ü  RR = 25

Ü  Trachea midline

Ü  No chest wall tenderness

Ü  Equal breath sounds bilaterally

• 

Primary Survey

C

Ü  Well perfused; CRT < 2sec

Ü  PR 63 bpm BP 140/75

Ü  Pelvis stable Abdo SNT

D

Ü  GCS 15 PEARL

E

Ü  Logroll NAD

• 

Immediate management

Ü  IV access: - Bloods taken

Ü  Immobilisation

Ü  O2

Ü  Warming: - Warmed IV Fluids - Warming blanket

Ü  ADT given

• 

Secondary survey

Ü  HEAD:

-  Loose teeth, bleeding from mouth

Ü  NECK:

-  No central C-spine tenderness

-  Sandbags and tape

-  Bilateral swelling and ecchymoses of the lateral neck

Ü  CHEST: NAD

• 

Secondary survey

Ü  ABDO:

- SNT; normal FAST

Ü  PELVIS:

- stable; plain X-ray normal

Ü  LIMBS:

- NAD

Ü  BACK:

- NAD

• 

Where to next?

Radiology department

Ü  CT BRAIN (14:50):

- no acute intracranial abnormality

Approx Injury Time: 10.40 Dispatched: 10.53 Arrive scene: 11.40 Depart: 12.08 ED: 13.04

Any other images?

Why or why not?

Radiology department

Ü  CT CAROTID ANGIO:

Approx Injury Time: 10.40 Dispatched: 10.53 Arrive scene: 11.40 Depart: 12.08 ED: 13.04

Radiology department

Ü  C-spine:

-  non-displaced fracture through right C2 lateral mass traversing the transverse foramen laterally

-  non-displaced fracture of the base of spinous process and a displaced fracture of transverse process of C3 on the right side

-  non-displaced fracture of the transverse process of C4 bilaterally traversing the transverse foramina

-  fracture through the transverse foramen of C5 on the left

Radiology department

Ü  CT CAROTID ANGIO:

-  right vertebral artery dissection

Any other images?

Radiology department

Ü  C-spine MRI (17:19):

-  oedema in the posterior spinal soft tissues of the mid to upper cervical spine

-  raises possibility of ligamentous injury

Where to next?

Progress Ü  Admitted to surgical ward

Ü  Vascular surgery and interventional radiology review:

-  observation

-  not for anti-coagulation

Ü  PCA fentanyl

Ü  Fax / max for mandibular fractures

Ü  Neurosurgical review:

-  cervical collar for six weeks

CTA neck - indications?

Screening criteria CTA Neck (blunt CVI)

Ü  Injury Mechanism:

Severe cervical hyper-extension, rotation or hyperflexion associated with:

-  displaced midface or complex mandibular fracture

-  closed head injury consistent with diffuse axonal injury

-  near hanging resulting in hypoxic brain injury

Screening criteria CTA Neck (blunt CVI)

Ü  Physical signs:

-  seat belt abrasion

-  other soft injury of anterior neck resulting in significant swelling or altered mental status

-  fracture in proximity to ICA or vertebral artery

-  basilar skull fracture involving carotid canal

-  cervical vertebral body fracture Ü 

Questions?