Week 6: Spine + Thoracic Trauma

It is difficult to identify cardiac tamponade by visual inspection only. Thus the first step should be opening the pericardium. Direct cardiac massage should be done after pericardium is opened and if no tamponade is found. Cross clamping of the aorta should be the next step if the patient still has no cardiac activity.

This clinical scenario depicts a patient with a tension pneumothorax. He has decreased blood pressure, decreased breath sounds, and, most important, an increased resistance to ventilation, which is the earliest sign of the development of a tension pneumothorax. Immediate decompression with a large-bore needle is the correct initial management in this condition.

Elevation of the right mainstem bronchus is suggestive of acute traumatic aortic disruption. Traumatic aortic disruption can result in immediate death if the degree of injury is severe, such as a complete transection. However, with less severe disruptions, the patient may survive and present to the ED. Prompt diagnosis and early intervention, can lead to a functional recovery.

Deviation of the trachea to the right (B), not the left suggests aortic injury. Deviation of the esophagus to the right (A), not the left suggests aortic injury. A left-sided hemothorax (D) suggests aortic injury, not a right hemothorax.

Two most common sites of aortic injury with blunt trauma are: Aortic isthmus and ascending aorta just proximal to the origin of the brachiocepahic vessels.

This patient has signs and symptoms of blunt cardiac injury. The most common chamber injured is the right ventricle as it lies most anterior in the thorax, immediately behind the sternum. Blunt cardiac injury results in myocardial contusion and “stunning” of the heart muscle. This can lead to dysrhythmias and heart failure. Cardiac contusion is most frequently caused by high-speed motor vehicle collisions or severe crush injuries. The most common etiology is a depressed sternal fracture. Symptoms of cardiac contusion include chest pain, shortness of breath, and palpitations. There is often external evidence of chest trauma including obvious depressed fractures of the sternum and steering wheel imprints. The diagnosis of significant blunt cardiac injury is made by electrocardiogram abnormalities (e.g. T wave inversions and frequent PVCs) and a serum troponin level. If either of these studies is abnormal, the patient should be admitted for telemetry monitoring.

This xray shows a Jefferson fracture, or a C1 burst fracture. These fractures occur with axial loading with vertical compression, an injury pattern that is common when a football player spears another player. When looking at the odontoid view of a c-spine film, the lateral masses of C1 shoulder align with the lateral parts of the C2 vertebral body. A Hangman’s fracture, or bilateral C2 pedicle fracture is best seen on a lateral view and shows C2 displaced anteriorly on C3. Odontoid fractures involve the odontoid process and are graded type I through type III depending on position.  Type II and III are both unstable fractures. Bilateral facet dislocation fractures are seen on lateral xrays of the c-spine and is characterized by anterior displacement greater than 50% diameter of vertebral body.

The correct answer is that this injury is associated with anterior cord syndrome. This patient has a flexion teardrop injury at C5 (note the wedge shaped fracture at the base of the vertebral body).  This is generally caused by extreme flexion and axial load, classically a diving injury. There is failure of the anterior column, often middle column, and disruption of the posterior ligamentous complex and the significant potential for cord injury from retropulsion of a fragment as a result.

Odontoid (dens) fractures are classified as Type I, II and III. Type I fractures are stable avulsion injuries to the tip of the odontoid. This patient has a Type II fracture, which is a fracture at the junction of the odontoid and body of C2. A Type III fracture is a fracture at the base of the the dens. Both Type II and III fractures are unstable because of ligamentous attachments. A bilateral C2 pedicle fracture is also known as a Hangman’s fracture and is seen on lateral xray as C2 being displaced anteriorly on C3. A teardrop fracture is an avulsion fracture of the anteroinferior portion of the vertebral body. Both of the former fractures patterns are unstable c-spine injuries.

A Clay-shoveler’s fracture, which is an avulsion of the spinous process of C6 or C7, is considered a stable cervical spine fracture. Other stable injuries include a unilateral facet dislocation and a type I odontoid fracture in which the tip of the odontoid is broken off is usually a stable cervical spine injury. This injury got its name from clay shovelers who were shoveling heavy clay that caused them to abruptly flex their neck while contracting their lower neck muscles. Now, most cases are due to direct trauma to the posterior neck.

Midline posterior bony cervical-spine tenderness is present if the patient reports pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or if pain can be elicited with direct palpation of any cervical spinal process. Patients are considered intoxicated if any of the following is present: a recent history provided by the patient or an observer of intoxication or ingestion of an intoxicating substance, evidence of intoxication on physical exam (e.g., slurred speech, ataxia, dysmetria, or other cerebellar findings), or any behavior consistent with intoxication. Patients may also be considered intoxicated if tests of bodily fluids are positive for alcohol or drugs that affect the level of alertness. An altered level of consciousness can include any of the following: a GCS of 14 or less; disorientation to person, place, time, or events; an inability to remember three objects at five minutes; or a delayed or inappropriate response to external stimuli. A focal neurologic deficit is defined by any neurologic finding on motor or sensory exam. No precise definition of painful or distracting injury is possible. Determination of this is left to the treating clinician.Therefore, only the 64-year-old man with no posterior midline cervical spine tenderness nor pain when he turns his head to the left can be clinically cleared.

A 22-year-old man with no posterior midline cervical spine tenderness and the odor of alcohol on his breath (A), a 32-year-old man with no posterior midline cervical spine tenderness with a GCS of 14 (B) and an 18-year-old woman with no posterior midline cervical spine tenderness and mild numbness to her right arm (D) do not meet NEXUS criteria and require imaging.

What 3 components of the Canadian cervical spine rules are not present in the NEXUS cervical spine rules? Age, mechanism, neck rotational

A pulmonary contusion occurs most commonly from blunt trauma and is the result of a direct bruise to the lung parenchyma followed by alveolar edema and hemorrhage. Although the initial radiographic findings (patchy, irregular to dense pulmonary infiltrates over the injured area) may be non-diagnostic and initial measurements of gaseous exchange may be normal, pulmonary function may be compromised over the ensuing few hours. Subsequent radiographs taken over several hours may demonstrate irregular opacification of the pulmonary parenchyma in a non-lobular pattern. Chest CT scans may demonstrate a contusion. Uncomplicated pulmonary contusions typically develop over the first 24 hours and resolve in approximately one week. Patients with severe pulmonary contusions experience difficulty breathing and hypoxia. Repeat chest radiographs show an increasing opacity in the affected lung fields. The condition is exacerbated if extensive crystalloid fluid resuscitation has been performed. Blood gas evaluation reveals an increased a-A gradient. Treatment is initially supplemental oxygen administration to reverse hypoxia; however, subsequent intubation and ventilation with positive end-expiratory pressure may be required. Other adjunctive therapies include pulmonary toilet and analgesia.

Lung Contusion

Air within the pleural cavity (A), or pneumothorax, is part of the differential diagnosis for this patient but is less likely to occur than a pulmonary contusion with a blunt trauma mechanism. Pulmonary contusions tend to worsen over time (B) and the patient’s initial presentation can change rapidly as there is an increase in alveolar edema and hemorrhage. Lung involvement is usually localized to a segment or a lobe (D). Adult respiratory distress syndrome (ARDS) is associated with diffuse lung involvement.