BCC4: Craig Hore on Trauma: CTA of the Neck and Thorax

•

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Craig Hore talks us through a case based discussion on trauma and CTA of the neck and thorax; and all in under 15 minutes! This talk was recorded at BCC4.

Santé & Médecine

Hay, hay…..CTA!!*
*(Warning: bad pun)

Craig Hore
Intensive Care Unit
Liverpool Hospital

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:
Dispatched:
Arrive scene:
Depart:
ED:

10.40
10.53
11.40
12.08
13.04

MIST
S:
Ü  BP= 140/75
Ü  GCS = 15
Ü  RR 25

HR= 63
Sats 96%

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

collar)

Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:

10.40
10.53
11.40
12.08
13.04

Primary Survey
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

Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:

10.40
10.53
11.40
12.08
13.04

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
•

Radiology department
Ü  CT BRAIN (14:50):

- no acute intracranial abnormality

Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:

10.40
10.53
11.40
12.08
13.04

Radiology department
Ü  CT CAROTID ANGIO:

Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:

10.40
10.53
11.40
12.08
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

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

$Progress Ü  Admitted to surgical ward Ü  Vascular surgery and interventional radiology review: -  observation -  not for anti-coagulation Ü  PCA fentanyl Ü  Fax / max for mandibular fractures Ü  Neurosurgical review: -  cervical collar for six weeks$

$Screening criteria CTA Neck (blunt CVI) Ü  Injury Mechanism: Severe cervical hyper-extension, rotation or hyperflexion associated with: -  displaced midface or complex mandibular fracture -  closed head injury consistent with diffuse axonal injury -  near hanging resulting in hypoxic brain injury$

$Screening criteria CTA Neck (blunt CVI) Ü  Physical signs: -  seat belt abrasion -  other soft injury of anterior neck resulting in significant swelling or altered mental status -  fracture in proximity to ICA or vertebral artery -  basilar skull fracture involving carotid canal -  cervical vertebral body fracture Ü$

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