Penetrating Neck Trauma and Laryngotracheal Injuries

Christopher Stoll · March 29, 2022 · Neck Trauma, EM

Penetrating Neck Trauma

ABCs

Assume a difficult airway in a patient with neck trauma.

· When bag-mask ventilation proves difficult due to airway distortion or physical characteristics, perform an awake, orotracheal intubation using a sedative without a paralytic

· Pneumothorax and hemothorax are present in up to 20% of patients with penetrating neck trauma. Listen for breath sides and signs of tension physiology

· Exsanguination is the proximate cause of death in most penetrating neck injury victims, apply direct pressure to wounds, but be careful not to simultaneously occlude both carotid arteries and or obstruct the airway.

Zones of the Neck

· Classically, zone II injuries undergo surgical exploration; zone I and III wounds undergo further evaluation

· The trajectory of the penetrating object can be difficult to determine clinically, and nearly half traverse multiple zones

· Zone II is injured most

· The platysma is a thin muscle that stretches from the facial muscles to the thorax, demarcating superficial from deep wounds.

· Wounds that do not penetrate the platysma are largely not life threatening.

Diagnosis and Treatment

· Any wound deep to the platysma raises concern for damage to the vital structures of the neck

· Instruct awake and cooperative patients to cough (to check for hemoptysis), to swallow saliva (to assess for dysphagia from esophageal injury), and to speak (to evaluate for laryngeal fracture)

· Assess the patient for “hard” and “soft” signs of injury

· Nine out of 10 patients with hard signs will have an injury requiring repair and should be rapidly transferred to the operating room or angiography suite.

· Remember “HARD BRUIT”

· Treatment: depends on the vessel involved and accessibility of the lesion.

· Options vary from observation to surgical repair to angiographic embolization or stenting.

Laryngotracheal Injury

· Rare, seen in about 1 in 30,000 ED visits

· Protection by the jaw, spine, and sternum

· In patients with head and neck trauma, it is the second most common cause of death after intracranial hemorrhage

· Usually seen in the setting of polytrauma and their presenting features often do not correlate with the extent of injury

· Most injuries are due to blunt trauma rather than penetrating trauma

· When the extended neck accelerates forward, striking a steering wheel or dashboard, the laryngeal structures are compressed posteriorly against the spine

· Injuries: endolaryngeal hematomas or lacerations managed conservatively with symptomatic treatment and observation, to complete tracheal transection requiring open laryngotracheal reconstruction

· Symptoms: dysphonia, dyspnea, dysphagia, stridor, neck pain, or hemoptysis

· Physical Exam: tracheal tenderness, subcutaneous emphysema, cyanosis, or persistent air leak after chest tube placement

· Management:

o The immediate first step in managing laryngotracheal injuries is always to establish a secure airway

o A fiberoptic bronchoscope will aid in visualization and minimize further airway trauma during intubation

o Injury distal to the carina should be managed with fiberoptic bronchoscopy with endotracheal tube placement in the mainstem bronchus opposite the side of injury.

o Once the airway is secured, a complete secondary survey should be performed to identify other traumatic injuries

o A chest X-ray should be obtained to identify pneumothorax, pneumomediastinum, tracheal deviation, or subcutaneous emphysema. A computed tomography of the neck will identify laryngeal fractures or dislocations.

· The cricoid cartilage is a complete ring, and fractures occur in two locations, most commonly anterior and posterior.

o Cricoid cartilage injuries are often concomitant with thyroid cartilage fractures

o The recurrent laryngeal nerve is commonly injured in cricoid cartilage fractures

o Endolaryngeal stents may be used to repair injuries with significant mucosal damage or those that disrupt the anterior laryngeal commissure.

· Treatment: Patients with grade I and II injuries can be managed medically; grade III, IV, and V injuries typically require operative intervention.

References

Tintinallis Emergency Medicine A Comprehensive Study Guide

Hippo EM

Rosh Review

https://rebelem.com/penetrating-neck-injuries/

Corneal Foreign Bodies

Christopher Stoll · March 18, 2022 · Corneal Foreign Body, EM

Corneal Foreign Bodies

· Corneal foreign bodies account for approximately 35% of all eye injuries seen in the ED

· Corneal foreign bodies are usually superficial and benign, but penetration into the globe can cause loss of vision

· Foreign bodies are generally small pieces of metal, wood, or plastic

· The presence of a corneal foreign body causes an inflammatory reaction, dilating blood vessels of the conjunctiva and causing edema of the lids, conjunctiva, and cornea

· If present for >24 hours, WBCs may migrate into the cornea and anterior chamber as a sign of iritis

· Occasionally, the foreign body may be visible with the naked eye

· Evert the lid to identify and remove other foreign bodies

· When a metallic foreign body is present for more than a few hours, a rust ring develops around the metal

· The presence of a gross hyphema or a microhyphema evident in the anterior chamber on slit lamp examination suggests globe perforation

· If the foreign body has penetrated the cornea, the tract of the projectile may be seen. The Seidel test may be positive with penetration of the globe

· Contact lens use should be avoided until the defect is fully healed or feels normal for at least 1 week.

Foreign Body Removal

· Anesthetize the cornea with a local anesthetic

· Anesthetizing both eyes can be helpful, because that can eliminate reflex blinking during attempts at foreign body removal

· Irrigate with normal saline first, as a very superficial foreign body may be irrigated off the cornea

· Next, try to dislodge the foreign body with a moistened cotton applicator (Q-tip)

· If the foreign body is tightly adherent to or embedded in the cornea, inspect the cornea using optic sectioning on the slit lamp to assess the depth of penetration

· Full-thickness corneal foreign bodies should be removed by an ophthalmologist

· For superficial foreign bodies, a 25-gauge needle (using needle bevel up) or a sterile foreign body spud (1 mm diameter) on an Alger brush (a low-speed, low-torque, battery-operated hand-held drill) can be used to remove the foreign body

· Using either the 25-gauge needle or the Alger brush, place the tip into the slit lamp beam using the naked eye

· Using the bevel-up edge of the tip of the 25-gauge needle, hook the edge of the foreign body and dislodge it. You may then lift it off the cornea using the previously moistened cotton applicator

· Alternatively, using the spinning tip of the Alger brush, the foreign body may be dislodged and removed with the cotton applicator as above.

· Administer tetanus toxoid as appropriate.

· Provide ophthalmology follow-up the NEXT DAY if the foreign body is in the central visual axis or if there is a residual rust ring.

· Otherwise, after complete removal of the foreign body, advise follow-up in 48 hours.

· After successful foreign body removal, discharge the patient with a prescription for topical antibiotics, cycloplegics, and oral analgesics.

Antibiotics

· Does Not Wear Contact Lens

o Erythromycin ointment qid x 3-5d OR

o Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR

o Ofloxacin 0.3% solution 2 drops q6 hours

· Wears Contact Lens

o Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones

o Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR

o Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR

o Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR

o Gentamicin 0.3% solution 2 drops six times for 5 days

Rust Ring Removal

· Metallic foreign bodies can create rust rings that are toxic to the corneal tissue.

· If a rust ring is present, the spud or an ophthalmic burr can remove superficial rust, but rust often reaccumulates by the next day, requiring additional burring.

· It is therefore not necessary to remove a rust ring in the ED if the patient can be seen by an ophthalmologist the next day

· Once the metallic foreign body is removed, the rust ring area softens overnight and can be more easily removed in the office the next day

· The deeper the stromal involvement, the higher is the risk of corneal scarring, so if rust ring removal is done in the ED, only perform superficial burring

· No ED drill burring should take place if the rust ring is in the visual axis (pupil) owing to the risk of causing visually significant scarring

References

Tintinalli’s Emergency Medicine a Comprehensive Study Guide 8th Edition

https://litfl.com/something-in-my-eye-doc/

https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343806

https://wikem.org/wiki/Ocular_foreign_body

POTD: Dialysis Catheter Placement

Christopher Stoll · March 11, 2022 · EM, Dialysis Catheter

General:

· Non-tunneled catheters and Tunneled cuffed catheters

o Non-tunneled: IJ, subclavian, femoral vein

o Tunneled: Cuffed catheters are inserted under fluoroscopic guidance into subclavian vein

· Catheters placed through the IJ or subclavian optimal tip location is at the junction of the superior vena cava and right atrium roughly around 15cm in length is appropriate.

· Subclavian vein less commonly used in acute emergency setting because as flow rates may be more reduced, the site carries associations with subsequent subclavian vein stenosis, making placement of a tunneled cuffed catheter or surgical AV fistula more difficult in the future.

· Femoral vein catheters should be >20cm in length so that the tip of the catheter can pass through the common iliac vein and reach the IVC

· Wikem Lengths:

o Right IJ: 12-15cm – less complications like kinking, obstruction, stenosis

o Left IJ: 15-20cm – more tortuous leading to reduced flows

o Femoral: 19-24cm – reduces patient mobility. If the RRT Circuit is constantly shutting down, or having low flows, check the HD catheter length. If the catheter tip is not long enough to reach the distal IVC, the RRT pump will often shut down secondary to inadequate flows.

Contraindications:

· Local infection over insertion site

· Thrombosis or stenosis within the target vein

· Distorted anatomy

· Local vascular injury

Complications:

· Similar complications to central lines

· Thrombosis

· Infection

· Pneumothorax

· Stenosis of central veins

· Dialysis catheter kinking or poor position of tip

Interesting Article from 2015:

https://www.ebmconsult.com/articles/catheter-related-blood-stream-infections-femoral-vs-internal-jugular-subclavian

· Two RCTs independently demonstrated no significant difference in major infection (sepsis) rates between the three sites.

· Similarly, a Cochrane review and systematic review/meta-analysis reported no significant difference in complications (CRBI or DVT) between the femoral and subclavian or IJ sites.

· Femoral line colonization, however, was intuitively noted to be increased in morbidly obese patients.

References

https://www.statpearls.com/ArticleLibrary/viewarticle/37044

https://www.ebmconsult.com/articles/catheter-related-blood-stream-infections-femoral-vs-internal-jugular-subclavian

https://emcrit.org/emcrit/femoral-central-lines/

https://wikem.org/wiki/Dialysis_catheter_placement