ED 2 Head and Neck Trauma

Question 1

borders of the anterior triangle?

Answer 1

superior: mandible
anterior: midline
posterior: sternocleidomastoid

Question 2

borders of the posterior triangle?

Answer 2

inferior: clavicle
posterior: trapezius
anterior: sternocleidomastoid

Question 3

what 4 structures do we worry most about with a zone 1 injury?

Answer 3

1) subclavian
2) aortic arch
3) trachea
4) c-spine roots

Question 4

what 4 structures do we worry most about with a zone 2 injury?

Answer 4

1) carotid/vertebral arteries
2) jugular vein
3) larynx
4) c-spine

Question 5

which structures do we worry about most with a zone 3 injury?

Answer 5

1) trachea
2) vertebral bodies
3) carotids, jugular
4) CN 9-12

Question 6

95 percent of penetrating neck wounds are caused by what? what makes up the other 5 percent?

Answer 6

knives and guns

5 percent MVA, sports

Question 7

what is the most important thing to know in terms of…

1) gunshot wound
2) knife wound

Answer 7

gunshot = caliber makes all the difference

knives = how big was it?

Question 8

high caliber gun shot wounds leave what type of injury pattern? what about low caliber?

Answer 8

high caliber = high velocity, predictable course

low caliber = low velocity, cavitate, track off in any direction (will shred you!)

Question 9

should you remove the knife when your patient presents with a knife in their neck?

Answer 9

no, it could be holding together their carotid! leave it

Question 10

if the ____ has not been violated, there is a very low likelihood that there has been a penetrating injury

Answer 10

platysma

Question 11

what are 4 signs of underlying injury from blunt trauma that is not so apparent just by looking at the patient?

Answer 11

1) hematemesis
2) odynophagia
3) voice changes
4) subQ emphysema

Question 12

if you have a known platysma injury or high suspicion of serious injury, what should your next step be?

Answer 12

SKIP IMAGING

transport to OR

Question 13

when is a chest x-ray absolutely mandatory in head/neck trauma?

Answer 13

with a zone 1 injury (worry about hitting apices of lung leading to pneumothorax)

Question 14

what is the imaging modality of choice if you suspect vascular injury in your neck trauma patient?

Answer 14

CT angiogram

Question 15

which imaging will use use for C-spine fractures?

Answer 15

CT scan

Question 16

what position should you place your neck trauma patient in while in the ED?

Answer 16

trendelberg position to avoid air embolus

Question 17

surgical exploration is indicated for these 5 considerations?

Answer 17

1) shock
2) expanding hematoma
3) impending airway obstruction
4) bruit
5) blood in aerodigestive tract (hemoptysis, hematemesis)

Question 18

if a neurological deficit is found on the contralateral side of the injury, what must you consider?

Answer 18

carotid/vertebral artery injury

Question 19

a depression of the forehead should clue you into what DX? why are these injuries bad?

Answer 19

frontal bone fracture

these are THICK bones so this is typically a high velocity injury – worry about brain and everything else

Question 20

where are the weakest aspects of the orbit? why do we worry about fractures here?

Answer 20

weakest = orbital floor and medial wall

fractures can lead to herniation of orbital contents into the sinus

Question 21

pain below the eye and difficulty with eye movements should clue you into what DX? how do you manage?

Answer 21

orbital floor fracture (inferior rectus can become entrapped)

refer to opthalmology ASAP!

Question 22

what is the imaging of choice for an orbital floor fracture?

Answer 22

non-contrast maxillofacial CT scan

Question 23

what are the only two facial fractures that can be seen on x-ray?

Answer 23

nasal and mandibular fractures

Question 24

what must you be sure not to miss with a nasal bridge fracture?

Answer 24

septal hematoma

also: your nose takes the front end of a hard hit, look for surrounding fractures

Question 25

your patient with a nasal bridge fracture will likely develop what?

Answer 25

raccoon eyes

Question 26

your patient presents with telecanthus, extremely swollen eyes, and constant tearing after trauma…whats going on?

Answer 26

nasoethmoidal FX

these are bad bad injuries, can damage medial canthus, lacrimal gland, nasofrontal duct, cribiform plate

Question 27

how do we manage nasoethmoid FX?

Answer 27

CT scan and move them along their way (usually from severe trauma)

Question 28

typical MOI of zygomatic arch fracture? how will they present?

Answer 28

MOI = direct punch to da face

present with tenderness, crepitus, and decreased ROM of mandible

Question 29

what type of fracture typically presents with 1 of 3 presentations of free flowing elements of their face?

Answer 29

maxillary FX

le fort classification

Question 30

lefort 1 classification has mobility of what? what other presentation?

Answer 30

palate and teeth

also facial edema

Question 31

lefort 2 classification has mobility of what? what other presentation?

Answer 31

maxilla

will likely have epistaxis and CSF rhinorrhea

Question 32

lefort 3 classification has mobility of what? what other presentation?

Answer 32

movement of all facial bones with respect to cranial base

they will also have facial elongation and flattening

Question 33

patient presents with a hanging mandible and you suspect a mandibular fracture. what should you do to DX?

Answer 33

tongue blade test

Question 34

gum and sublingual ecchymosis should clue you into which diagnosis?

Answer 34

mandible fracture

Question 35

where should you store avulsed teeth if tooth is intact with the roots?

Answer 35

whole milk!

don’t rinse or scrub tooth (need the periodontal membrane and ligament intact)

Question 36

what does a positive halo test show?

Answer 36

separation of blood and CSF on gauze in target-like pattern; useful in basilar skull fractures

Question 37

what should you always do if you suspect fracture through the sinuses?

Answer 37

prescribe ABX!

kefzol, clindamycin, amoxicillin

Question 38

if there is a CSF leak, what should you prescribe?

Answer 38

vancomycin + ceftazidime

Question 39

what type of bandage is used for a mandible fracture?

Answer 39

barton bandage