I ran over my own face

1. I ran over my own face Raj Upadhyay R3 –CCFP/EM

2. Urgence Sante` • 77 M, found conscious under his car • Has multiple lacerations and bleeds on his face • 21:43 -- 140/80, RR 20, P84, 100% on 15L • Arrives in ER 22:14

3. Pt. is in the Trauma Bay…

4. Airway Assessment • Pt having difficulty speaking • ++blood in the mouth • Significant facial trauma; looks swollen and deformed

5. Airway Assessment Continued • No subcutaneous emphysema • No obvious laryngeal trauma • Trachaea midline • Short fat neck, small mouth

6. Airway Management • Blood suctioned with no avail • RSI --Etomidate 30 + Succinylcholine 100 • Relatively difficult intubation • Tube placement confirmed by qualitative CO2 detector and auscultation

7. Breathing Assesment • Good A/E bilaterally • O2 sats 100% on FiO2 of 50% • Remainder unremarkable

8. Circulation Assesment • BP now 183/72 • P 80 • Good peripheral circulation • Other than the face, no obvious source of bleeding

9. Disability • Difficulty opening his eyes secondary to swelling • Difficulty talking • Initially and may have been confused in the ambulance • Overall GCS 14-15/15

10. Exposure • Left scalp hematoma • Bilateral periorbital ecchymosis • Multiple lacerations around the lips, chin, and forehead oozing significant quantity of blood • Abrasions and lacerations on both hands and feet

11. Adjuncts • Foley and NGT inserted • Fast ultrasound normal • CXR widened mediastinum with no hemo/pneumo-thorax • ETT placement appropriate

12. Secondary Survey • Hyphema of left eye with upper and lower lid hematoma • Laceration of lt medial canthus; no obvious corneal lacerations

13. Secondary Survey Continued • Blood in the nares and mouth with multiple cuts inside the mouth • Periorbital ecchymosis and swelling • No other signs of basal skull fracture

14. Secondary Survey Continued • Step deformity in the lt zygoma • Nil in neck, chest, abdo, pelvis • No step-deformities in TLS spines • No blood in the rectum

15. AMPLE • Paramedics have some of his pills that his frantic wife handed to them: • Coumadin, altace, diltiazam, HCTZ

16. Ample Continued • No known allergies • History of high blood pressure and some strokes in the past • Last meal supper that night • Significant ETOH abuse

17. Event History

18. Further Investigations/ Management??

19. Bleed and Infection control • Vit K • FFP • Td • Ancef • Cocktail of shame

20. CT Head • No acute injury • Chronic ischemic changes • Atrophic temporal lobe • Lacune left thalamus • Old left and right cerebellar infarcts

21. CT Scan of Facial Bones • Left eye blowout # • Lt zygoma# • Very displaced bilateral maxillary wall# • Ruptured left globe with air in the orbits • Masserated left lateral and medial recti muscles • Bilateral nasal bones #

22. Radiologic Evaluation Continued • CT chest: Small lung contusions bilaterally, otherwise normal • CT abdomen normal • CT C-spine normal

23. Now What?

24. Plastics • Sutured some of the facial lacerations • Other lacerations not amenable to suturing because of significant progression of swelling • “Needs ORIF in a few days when stabilized”

25. Optho • Exploration of the left globe the same night • Left lateral canthotomy • No rupture found

26. Trauma • Suggested admission to ICU • Will follow

27. Course in Hospital

28. PTD#1 • Continued bleeding from the mouth overnight, 1-2 L of blood suctioned • Transfused 6U PRBC and 12U FFP • Continued bleeding despite normalization of coagulation • Sedated on Propafol, morphine throughout GCS: E* V1T M6

29. PTD#1 Continued • Face swollen 2 times its original size • BP 150-190 systolic, no significant tachy • ? Options to control bleeding?

30. PTD#1 Continued • Nipride drip started to control BP • Sent to angio to embolize the bleeding vessels: Sphenopalatine arteries embolized bilaterally

31. PTD#1 Continued • In the angio-suite BP dropped to 50 systolic and remained there for 15-20 minutes • Finally restored after 1 dose of neosynephrine

32. PTD#2 • Plastics requests clearance of C-spine prior to OR • Fluids: 13L positive balance • Diuresed for CHF on CXR • Pt taken for tracheostomy

33. Neurologic Exam • GCS 3T  5T (V1T, E3, M1) when off sedation • Bilateral flaccid paralysis • No lateral movement of the eyelids • ?Obeying commands to open and close the eyes.

34. ? DDx for Neurologic Deterioration?

35. DDx • Brainstem: pontine infarction –locked in state (secondary to athrosclerosis, hypotention, or arterial injury to the neck) • Spinal cord: compression, transverse myelitis • Peripheral nerves: guillain-barre syndrome, critical illness polyneuropathy

36. DDx cont.. • Neuromuscular junction: delayed neuromuscular blockade, myesthenia gravis • Skeletal muscles: hyperkalemia, hypophosphatemia or hypomagnesemia, critical illness myopathy, acute alcoholic myopathy

37. Workup • Normal CBC, electrolytes, Ca, Mg, PO4, LFT; stable BUN/ Cr • MRI of head: new large pontine infarction • CTA neck: bilateral athrosclerotic stenosis is ICA, Normal Rt vertebral artery and opacification of Lt vertebral artery from C3 up

38. Vascular trauma in the neck

39. Intro • BVI of neck are potentially the most devastating and underdiagnosed injuries seen following stabilization of a polytrauma patient • Commonly associated with other confounding injuries

40. Associated Injuries • Closed head injuries • Facial fractures • Basal skull fractures through carotid foramen • Upper thoracic fractures • C-spine injuries

41. Mechanism of Injury • MVC (most common) • Any injury with lateral hyperflexion/ hyperextention of the neck resulting in traction or compression of the arteries of the neck • May be associated with relatively minor trauma

42. Incidence • No large population based studies are available • Several large level 1 trauma centers report detection rate <1% of all blunt trauma patients

43. Incidence • Increasing incidence seen in recent years because of more aggressive investigation attempts. • 80% ICA;20% vertebral artery

44. Diagnostic Modalities • Angiogram: gold standard • CTA: improving technology/ sensitivity rates described >90% • MRA: may define other associated injuries and more detailed description of resultant and concominant brain pathology

45. Diagnostic Uncertainty • Variability of presentation • Cost and invasiveness of diagnostic modalities • Who to screen given the low incidence

46. Proposed indication for screening • Carotid canal fractures • Neck hematomas • Neurologic deficits not explained by CT head Journal of trauma vol 45(6) December 1998. 997-1004

47. Theraputic Modalities • Antiplatelet therapies: ASA, Plavix • Heprinization: early vs. delayed • Coumadin short vs. long term • Surgical repair: open vs. endovascular techniques

48. Theraputic Uncertainties • No randomized trials; Only retrospective studies available • No significant difference in morbidities and in hospital mortality (all cause) when antiplatelet therapies compared to anticoagulation.

49. Theraputic Uncertainties Continued • No difference in early vs late heprinization • Significant difference between treated and untreated group • Small number of patients • Retrospective evaluations

50. Theraputic Uncertainties Continued • No randomization • Single centers • Untreated group more severe injuries precluding them from anticoagulation Vol 2, 2004. Cochraine review.