01-2 Trauma - Head, Neck, Chest

Question 1

An 18-year-old man arrives in the ER with an ax firmly implanted into his head. Although it is clear from the size of the ax blade and the penetration that he has sustained an intracranial wound, he is awake and alert and hemodynamically stable.

Answer 1

The management of penetrating wounds is fairly straightforward. There will be exceptions, but as a rule the damage done to the internal organs (in this case the brain) will need to be repaired surgically. This man will go to the OR, and it will be there, under anesthesia and with full control, that the ax will be removed. An important detail when the weapon is embedded in the patient and part of it is sticking out is not to remove it in the ER or at the scene of the accident.

Question 2

In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and CT scan shows an underlying linear skull fracture. He is neurologically intact and gives no history of having lost consciousness.

Answer 2

The rule in skull fractures is that if they are closed (no overlying wound) and asymptomatic, they are left alone. If they are open (like this one), the laceration has to be cleaned and closed, but if not comminuted or depressed, it can be done in the ER.

Question 3

In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and CT scan shows an underlying comminuted, depressed skull fracture. He is neurologically intact and gives no history of having lost consciousness.

Answer 3

This one goes to the OR for cleaning and repair, and possible craniotomy.

Question 4

A pedestrian is hit by a car. When brought to the ER he has minor bruises and lacerations but is otherwise quite well, with a completely normal neurologic exam. However, the ambulance crew reports that he was unconscious at the site, and although he woke up during the ambulance ride and is now completely lucid, he does not remember how the accident happened.

Answer 4

Anyone who has been hit over the head and has become unconscious gets a computed tomography (CT) scan, looking for intracranial hematomas. If the CT scan and the neurologic examination are normal, he can go home—provided his family is willing to wake him up frequently over the next 24 hours to make sure he is not going into coma.

Question 5

I. A pedestrian is hit by a car. He arrives in the ER in coma. He has ecchymosis around both eyes (raccoon eyes).
II. A pedestrian is hit by a car. He arrives in the ER in coma. He has clear fluid dripping out of his nose.
III. A pedestrian is hit by a car. He arrives in the ER in coma. He has clear fluid dripping from the ear.
IV. A pedestrian is hit by a car. He arrives in the ER in coma. He has ecchymosis behind the ear.

Answer 5

Basal skull fracture—and because the physical findings are so characteristic, they may be found as diagnostic options in exam questions of the long-listmatch- with-the-diagnosis type. They will all get a CT scan because the patient is in a coma. The scan will show the fractures, but nothing will actually be done about them. Typically, the leak of cerebrospinal fluid (CSF) will stop by itself, and although there is a higher risk of meningitis, prophylactic antibiotics have not proven to be of use. The CT scan should be extended to include the neck because the most important feature of these four vignettes is that the patients sustained significant trauma to the head and thus are at risk for lesions of the cervical spine.

Question 6

A 14-year-old boy is hit over the side of the head with a baseball bat. He loses consciousness for a few minutes, but he recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated. There are signs of contralateral hemiparesis.

Answer 6

What is it? Acute epidural hematoma (90% likely to be right side).
Diagnosis. CT scan, which will show a lens-shaped hematoma and deviation of the midline structures to the opposite side.
Management. Emergency surgical decompression (craniotomy). Good prognosis if treated, fatal within hours if it is not.

Question 7

A 32-year-old man is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride, and arrives at the ER in deep coma with a fixed, dilated right pupil and contralateral hemiparesis.

Answer 7

What is it? Could be acute epidural hematoma, but acute subdural is better bet. (Big-time trauma, sicker patient.)
Diagnosis. CT scan will show semilunar, crescent-shaped hematoma. Given the lateralizing signs, it will also show deviation of the midline structures to the opposite side. Be sure to check the cervical spine also!
Management. Emergency craniotomy. Evacuation of the clot often leads to significant improvement, particularly when the brain is being pushed to the side; but ultimate prognosis is poor because of accompanying parenchymal injury.

Question 8

A man involved in a high-speed, head-on automobile collision is in coma. He has never had any lateralizing signs, and CT scan shows a small crescentshaped hematoma, but there is no deviation of the midline structures.

Answer 8

Another subdural hematoma, but without lateralizing signs and evidence of displacement of the midline structures, surgery has little to offer. Management will probably be directed at controlling ICP, as detailed in the next vignette.

Question 9

A patient involved in a head-on, high-speed automobile collision arrives in the ER in deep coma, with bilateral fixed dilated pupils. CT scan of the head shows diffuse blurring of the gray-white mass interface and multiple small punctate hemorrhages. There is no single large hematoma or displacement of the midline structures.

Answer 9

The CT findings are classic for diffuse axonal injury. Prognosis is terrible, and surgery cannot help. Therapy will be directed at preventing further injury from increased ICP. Probably ICP monitoring will be in order. First-line measures to lower ICP include head elevation, hyperventilation, and avoidance of fluid overload. Mannitol and furosemide are next in line. Do not
overdo the treatment. Lowering ICP is not the ultimate goal; preserving brain perfusion is. Thus, diuretics that lead to systemic hypotension, or measures that produce excessive cerebral vasoconstriction may be counterproductive. Hyperventilation is indicated when there are clinical signs of herniation, and the goal is a PCO2 of 35. Lowering oxygen demand may also help.
Sedation has been used for that purpose, and hypothermia is currently advocated for the same
reason.

Question 10

A 77-year-old man becomes “senile” over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.

Answer 10

What is it? Chronic subdural hematoma (venous bleeding, size 7 brain in size 8 skull).
Diagnosis. CT scan.
Management. Surgical decompression (craniotomy). Spectacular improvement expected

Question 11

A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma with fixed, dilated pupils. He has multiple other injuries, including fractures of the extremities. His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What kind of intracranial bleeding is responsible for the low blood pressure (BP) and high pulse rate?

Answer 11

I trust you remember this very same vignette from the review of shock. Shock does not result from intracranial bleeding (not enough room in the head for sufficient blood loss to cause shock). Look for answer of significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures).

Question 12

A man has been shot in the neck and his blood pressure is rapidly deteriorating.

Answer 12

Not much detail, but the point of this abbreviated vignette is that penetrating wounds anywhere in the neck need immediate surgical exploration if the patient is unstable (i.e., if vital signs are deteriorating).

Question 13

A 42-year-old man is shot once with a .22-caliber revolver. The entrance wound is in the anterior left side of the neck, at the level of the thyroid cartilage. X-rays
show that the bullet is embedded in the right scalene muscle. He is spitting and coughing blood and has an expanding hematoma under the entrance wound. His blood pressure responded promptly to fluid administration, and he has remained stable.

Answer 13

A clear-cut case of a penetrating wound in the middle of the neck (zone II) that has alarming symptoms and therefore follows the rule (rather than the exception) for all penetrating injuries: immediate surgical exploration is required. This is true even though he is stable. The middle of the neck is packed with structures that should not have holes in them.

Question 14

A young man is shot in the upper part of the neck. Evaluation of the entrance and exit wounds indicates that the trajectory is all above the level of the angle of the mandible. A steady trickle of blood flows from both wounds, and does not seem to respond to local pressure. The patient is drunk and combative but seems to be otherwise stable.

Answer 14

Now we are getting into the exceptions. In this very high level of the neck there is no trachea or esophagus to worry about, but only pharynx—injuries of which are inconsequential. Vascular injuries are the only potential problem, but getting to them surgically is not easy. Thus angiography is a better choice, both for diagnosis and potentially for embolization.

Question 15

A young man suffers a gunshot wound to the base of his neck. The entrance and exit wounds are above the clavicles but below the cricoid cartilage. He is hemodynamically stable.

Answer 15

This is another part of the neck (or the thoracic outlet if you prefer) that is crammed with vital structures that should be promptly repaired if they are injured. But precise preoperative diagnosis would help plan the incision and surgical approach. If the patient is stable, the standard workup includes angiography, soluble-contrast esophagogram (followed by barium if negative), esophagoscopy, and bronchoscopy.

Question 16

In the course of a bar fight, a young man is stabbed once in the neck. The entrance wound is in front of the sternomastoid muscle on the right, at the
level of the thyroid cartilage. The patient is completely asymptomatic, and his vital signs are completely normal.

Answer 16

In stab wounds to the upper and middle zones of the neck, completely asymptomatic patients can be closely observed but investigate if symptoms arise.

Question 17

A patient who was the unbelted right front-seat passenger in a car flies through the windshield when the car crashes into a telephone pole at 30 miles an hour. He arrives in the ER strapped to a headboard and with sandbags on both sides of the neck. He has multiple facial lacerations but is otherwise stable. Examination of the neck reveals persistent pain and tenderness to palpation over the posterior midline of the neck. Neurologic examination is normal.

Answer 17

Every patient with head injuries from blunt trauma is a candidate for cervical spine injury. The paramedics transport everyone as if they had such injury. Neurologic deficits provide a clear answer (more about those later), but in the patient who arrives neurologically intact, we don’t want to make the diagnosis by allowing neurologic deficits to develop. Persistent local pain over the suspected area should trigger radiologic evaluation, which is best done with a CT scan of the neck.

Question 18

An 18-year-old street fighter gets stabbed in the back, just to the right side of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side.

Answer 18

What is it? Probably no one in real life will have such a neat, clear-cut syndrome, but for purposes of examination vignettes this is a classic spinal cord hemisection, better known as Brown- Séquard syndrome.

Question 19

A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature
sensation on both sides distal to the injury, while showing preservation of vibratory sense and position.

Answer 19

What is it? Anterior cord syndrome.

Question 20

An elderly man is involved in a rear-end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain on both upper extremities while maintaining good motor function in his legs.

Answer 20

What is it? Central cord syndrome.
Management for cases 21–23: Start with the precise diagnosis. CT scans are good to look at the cervical bones. To look at the cord, magnetic resonance imaging (MRI) is better. Beyond that, I doubt that the long and complicated management of spinal cord injuries will be tested on the examination.

Question 21

A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. Chest x-ray confirms
the presence of a rib fracture, with no other abnormal findings.

Answer 21

A plain rib fracture is the most common chest injury. It is bothersome but trivial in most people, but it can be hazardous in the elderly (splinting and hypoventilation leading to pneumonia). The key to treatment is local pain relief, best achieved by nerve block and epidural catheter. Beware of the wrong answers that call for strapping or binding.

Question 22

A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds on the right, which is hyperresonant to percussion.

Answer 22

What is it? Plain pneumothorax.
Diagnosis. There is time to get a chest x-ray if the option is offered.
Management. Chest tube to underwater seal and suction. If given an option for location, at the fifth intercostal space, mid-axillary line.

Question 23

A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. The base of the right chest has no breath sounds and is dull to percussion. He has faint distant breath sounds at the
apex.

Answer 23

What is it? Sounds more like hemothorax.
Diagnosis. Chest x-ray. If confirmed, treatment is chest tube on the right, at the base of the pleural cavity. If contaminated blood is allowed to stay there, it will develop an empyema with potentially a lot of future
problems.

Question 24

A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds at the right base, and only faint distant breath sounds at the apex. The right base is dull to percussion. Chest x-ray confirms the presence of a hemothorax. A chest tube placed at the right pleural base recovers 120 ml of blood and drains another 20 ml in the next hour.

Answer 24

Management. The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure) and stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterward.

Question 25

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure of 95 over 70, pulse rate of 100. No breath sounds are heard over the right chest, which is dull to percussion. Chest x-ray shows a large hemothorax on the right. A chest tube placed at the right pleural base recovers 1,250 ml of blood.

Answer 25

Management. The rare exception who is bleeding from a systemic vessel or a major vessel in the pulmonary circuit. Will need thoracotomy or thoracoscopy to ligate the vessel. The most likely culprit will be an intercostal artery. Criteria for proceeding with surgical intervention at the outset are given by some as recovering more than 1,000 ml, by others as exceeding 1,500 ml.

Question 26

A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds at the right base, and only faint distant breath sounds at the apex. The right base is dull to percussion. Chest x-ray confirms the presence of a hemothorax. A chest tube placed at the right pleural base recovers 350 ml of blood. Over the ensuing 4 hours he continues to drain between 200 and 300 ml of blood per hour.

Answer 26

Another example of bleeding from a systemic vessel (most likely an intercostal) that will require a thoracotomy. Subsequent bleeding requires surgical intervention if it adds up to at least 600 ml in the next 6 hours.

Question 27

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Hyperresonant to percussion at the apex of the right chest, dull at the base. Chest x-ray shows one single, large air-fluid level.

Answer 27

What is it? Hemopneumothorax. Chest tube at the base to make sure the blood is drained. Subsequent criteria as in the previous vignettes.

Question 28

A worker has been injured at an explosion in a factory. He has multiple cuts and lacerations from flying debris, and he is obviously short of breath. The paramedics at the scene of the accident ascertain that he has a large, flaplike wound in the chest wall, about 5 cm in diameter, and he sucks air through it with every inspiratory effort.

Answer 28

The classic sucking chest wound. It needs to be covered to prevent further air intake (Vaseline gauze is ideal), but it must be allowed to let air out. Taping the dressing on three sides, creating a one-way flap (this time in the proper direction) is an option. Once in the hospital, he will need a chest tube.

Question 29

A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is in moderate respiratory distress. She has multiple
bruises over the chest, and multiple sites of point tenderness over the ribs. X-rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.

Answer 29

What is it? Classic physical diagnosis finding of paradoxical breathing, leading to classic diagnosis of flail chest. Diagnosis is easy, but management requires a long discussion.
Management. The management of severe blunt trauma to the chest from a deceleration injury has 3 components: treatment of the obvious lesion, monitoring for other pathology that may not become obvious until a day or two later, and actively investigating the potential presence of a silent killer, traumatic transection of the aorta. Let’s look at each of those.
In this case, the obvious lesion is flail chest. The problem there is the underlying pulmonary contusion, which is treated with fluid restriction, diuretics, and close monitoring of blood gases. Should blood gases deteriorate, the patient needs to be placed on a respirator and get bilateral chest tubes (the latter are needed because lungs punctured by the broken ribs could leak air once positive pressure ventilation is started, which could lead to a tension pneumothorax).
Monitoring is needed over the next 48 hours for possible signs of pulmonary or myocardial contusion. Repeated chest x-rays, blood gases, EKGs, and troponins are needed.
Traumatic transection of the aorta is best diagnosed with spiral CT scan of the chest, enhanced by intravenous dye (CT angio).

Question 30

A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is breathing well. She has multiple bruises over the chest, and multiple sites of point tenderness over the ribs. X-rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on x-rays and she is in respiratory distress.

Answer 30

What is it? Pulmonary contusion. It does not always show up right away, may become evident 1 or 2 days after the trauma.
Management. Fluid restriction, diuretics, respiratory support. The latter is key, with intubation, mechanical ventilation, and positive end-expiratory pressure (PEEP) if needed.

Question 31

A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the ER gasping for breath, cyanotic at the lips, with flaring nostrils.
There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is hyperresonant to percussion.

Answer 31

What is it? A variation on an old theme: classic picture for tension pneumothorax—but where is the penetrating trauma? The fractured ribs can act as a penetrating weapon.
Management. Needle through the upper anterior chest wall to let the air rush out, followed by chest tube to the left. Do not fall for the option of getting x-ray first, but you need them later to verify correct position of the chest tube. This is a deceleration injury. You also need to look for traumatic transection of the aorta.

Question 32

A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a gritty feeling of bone grating on bone, elicited by palpation.

Answer 32

What is it? Obviously a sternal fracture (which a lateral chest x-ray will confirm), but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta.
Diagnosis. Diagnose (and treat) myocardial contusion. As you would an MI: primarily ECG, troponins (other cardiac enzymes are not very sensitive in this setting), and control arrhythmias as they develop. But the real important test would be spiral CT scan looking for an aortic rupture.

Question 33

A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical examination shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest x-ray shows multiple air fluid levels in the left chest.

Answer 33

What is it? Classic for traumatic diaphragmatic rupture. It is always on the left.
Diagnosis. Not really needed. A nasogastric (NG) tube curling up into the left chest might be an added tidbit. In suspicious cases, laparoscopic evaluation is indicated.
Management. Surgical repair.

Question 34

A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed, his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the ER he is found to be remarkably stable, although he has multiple extremity fractures. A chest x-ray shows fracture of the left first rib and widened mediastinum.

Answer 34

What is it? Actually a real case. Classic for traumatic rupture of the aorta: King-size trauma, fracture of a hard-to-break bone (it could be first rib, scapula, or sternum), and the telltale hint of widened mediastinum.
Diagnosis. Spiral CT scan
Management. Emergency surgical repair.

Question 35

A 34-year-old woman suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, head trauma, and pneumothorax on the left side. Shortly after initial examination it is noted that she is developing
progressive subcutaneous emphysema all over her upper chest and lower neck.

Answer 35

What is it? Three things can give thoracic subcutaneous emphysema. One is rupture of the esophagus, but the setting there is always after endoscopy (for which it is diagnostic). The second one is tension pneumothorax, but there the alarming findings are all the others already reviewed—the emphysema is barely a footnote. That leaves the third (which is the case): traumatic rupture of the trachea or major bronchus.
Diagnosis. Chest x-ray would confirm the presence of air in the tissues.
Management. Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure an airway. Surgical repair after that.

Question 36

A patient who had received a chest tube for a traumatic pneumothorax is noted to be putting out a very large amount of air through the tube (a large air leak), and his collapsed lung is not expanding.

Answer 36

Another presentation for a major bronchial injury.

Question 37

A patient who sustained a penetrating injury of the chest has been intubated and placed on a respirator, and a chest tube has been placed in the appropriate pleural cavity. The patient had been hemodynamically stable throughout, but then suddenly goes into cardiac arrest.

Answer 37

A typical scenario for air embolism, from an injured bronchus to a nearby injured pulmonary vein, and from there to the left ventricle. Immediate management includes cardiac massage, followed by thoracotomy.

Question 38

I. During the performance of a supraclavicular node biopsy under local anesthesia, suddenly a hissing sound is heard, and the patient drops dead.
II. A patient who is receiving total parenteral nutrition through a central venous line becomes frustrated because the nurses are not answering his call button,
so he gets up and out of bed, and disconnects his central line from the IV tubing. With the open catheter dangling, he takes two steps in the direction of the nurses station, and drops dead.

Answer 38

Another two examples of air embolism. Other thoracic calamities, like tension pneumothorax or continued bleeding, will produce severe deterioration of vital signs—but there will be a sequence from being okay to becoming terribly ill. When vignettes give you sudden death, think of air embolism. This is very uncommon.

Question 39

A patient who sustained severe blunt trauma, including multiple fractures of long bones, becomes disoriented about 12 hours after admission. Shortly thereafter he develops petechial rashes in the axillae and neck, fever, and tachycardia. A few hours later he has a full-blown picture of respiratory distress with hypoxemia. Chest x-ray shows bilateral patchy infiltrates, and his platelet
count is low.

Answer 39

This is not a chest injury, but it is included here because its main problem is respiratory distress. You probably recognized already the fat embolism syndrome. It is not clear how specific is the laboratory finding of fat droplets in the urine, but it does not matter: the mainstay of therapy is respiratory support—which would be needed regardless of the etiology of the respiratory distress. Heparin, steroids, alcohol, and low-molecular-weight dextran have all been used, but are of questionable value.