I ran over my own faceI ran over my own face

Raj Upadhyay

R3 –CCFP/EM

Urgence Sante`Urgence Sante`

77 M, found conscious under his carHas multiple lacerations and bleeds on his

face

21:43 -- 140/80, RR 20, P84, 100% on 15L

Arrives in ER 22:14

Pt. is in the Trauma Bay…Pt. is in the Trauma Bay…

Airway AssessmentAirway Assessment

Pt having difficulty speaking++blood in the mouth Significant facial trauma; looks swollen and

deformed

Airway Assessment Airway Assessment ContinuedContinued

No subcutaneous emphysemaNo obvious laryngeal traumaTrachaea midlineShort fat neck, small mouth

Airway ManagementAirway Management

Blood suctioned with no availRSI --Etomidate 30 + Succinylcholine 100Relatively difficult intubationTube placement confirmed by qualitative

CO2 detector and auscultation

Breathing AssesmentBreathing Assesment

Good A/E bilaterallyO2 sats 100% on FiO2 of 50%Remainder unremarkable

Circulation AssesmentCirculation Assesment

BP now 183/72P 80Good peripheral circulationOther than the face, no obvious source of

bleeding

DisabilityDisability

Difficulty opening his eyes secondary to swelling

Difficulty talking Initially and may have been confused in the

ambulanceOverall GCS 14-15/15

ExposureExposure

Left scalp hematomaBilateral periorbital ecchymosisMultiple lacerations around the lips, chin,

and forehead oozing significant quantity of blood

Abrasions and lacerations on both hands and feet

AdjunctsAdjuncts

Foley and NGT insertedFast ultrasound normalCXR widened mediastinum with no

hemo/pneumo-thorax ETT placement appropriate

Secondary SurveySecondary Survey

Hyphema of left eye with upper and lower lid hematoma

Laceration of lt medial canthus; no obvious corneal lacerations

Secondary Survey ContinuedSecondary 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

Secondary Survey ContinuedSecondary Survey Continued

Step deformity in the lt zygomaNil in neck, chest, abdo, pelvisNo step-deformities in TLS spinesNo blood in the rectum

AMPLEAMPLE

Paramedics have some of his pills that his frantic wife handed to them:

Coumadin, altace, diltiazam, HCTZ

Ample ContinuedAmple Continued

No known allergiesHistory of high blood pressure and some

strokes in the pastLast meal supper that nightSignificant ETOH abuse

Event HistoryEvent History

Further Investigations/ Further Investigations/ Management??Management??

Bleed and Infection controlBleed and Infection control

Vit KFFPTdAncefCocktail of shame

CT HeadCT Head

No acute injuryChronic ischemic changesAtrophic temporal lobe Lacune left thalamus Old left and right cerebellar infarcts

CT Scan of Facial BonesCT Scan of Facial Bones

Left eye blowout #Lt zygoma#Very displaced bilateral maxillary wall# Ruptured left globe with air in the orbitsMasserated left lateral and medial recti

musclesBilateral nasal bones #

Radiologic Evaluation Radiologic Evaluation ContinuedContinued

CT chest: Small lung contusions bilaterally, otherwise normal

CT abdomen normalCT C-spine normal

Now What?Now What?

PlasticsPlastics

Sutured some of the facial lacerationsOther lacerations not amenable to suturing

because of significant progression of swelling

“Needs ORIF in a few days when stabilized”

OpthoOptho

Exploration of the left globe the same nightLeft lateral canthotomyNo rupture found

TraumaTrauma

Suggested admission to ICUWill follow

Course in HospitalCourse in Hospital

PTD#1PTD#1

Continued bleeding from the mouth overnight, 1-2 L of blood suctioned

Transfused 6U PRBC and 12U FFPContinued bleeding despite normalization

of coagulationSedated on Propafol, morphine throughout

GCS: E* V1T M6

PTD#1 ContinuedPTD#1 Continued

Face swollen 2 times its original sizeBP 150-190 systolic, no significant tachy

? Options to control bleeding?

PTD#1 ContinuedPTD#1 Continued

Nipride drip started to control BPSent to angio to embolize the bleeding

vessels: Sphenopalatine arteries embolized bilaterally

PTD#1 ContinuedPTD#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

PTD#2PTD#2

Plastics requests clearance of C-spine prior to OR

Fluids: 13L positive balance Diuresed for CHF on CXRPt taken for tracheostomy

Neurologic ExamNeurologic Exam

GCS 3T 5T (V1T, E3, M1) when off sedation

Bilateral flaccid paralysisNo lateral movement of the eyelids?Obeying commands to open and close the

eyes.

? DDx for Neurologic ? DDx for Neurologic Deterioration?Deterioration?

DDxDDx

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

DDx cont..DDx cont..

Neuromuscular junction: delayed neuromuscular blockade, myesthenia gravis

Skeletal muscles: hyperkalemia, hypophosphatemia or hypomagnesemia, critical illness myopathy, acute alcoholic myopathy

WorkupWorkup

Normal CBC, electrolytes, Ca, Mg, PO4, LFT; stable BUN/ Cr

MRI of head: new large pontine infarctionCTA neck: bilateral athrosclerotic stenosis

is ICA, Normal Rt vertebral artery and opacification of Lt vertebral artery from C3 up

Vascular trauma in the neckVascular trauma in the neck

IntroIntro

BVI of neck are potentially the most devastating and underdiagnosed injuries seen following stabilization of a polytrauma patient

Commonly associated with other confounding injuries

Associated InjuriesAssociated Injuries

Closed head injuries Facial fracturesBasal skull fractures through carotid

foramenUpper thoracic fracturesC-spine injuries

Mechanism of InjuryMechanism 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

IncidenceIncidence

No large population based studies are available

Several large level 1 trauma centers report detection rate <1% of all blunt trauma patients

IncidenceIncidence

Increasing incidence seen in recent years because of more aggressive investigation attempts.

80% ICA;20% vertebral artery

Diagnostic ModalitiesDiagnostic Modalities

Angiogram: gold standardCTA: improving technology/ sensitivity

rates described >90%MRA: may define other associated injuries

and more detailed description of resultant and concominant brain pathology

Diagnostic UncertaintyDiagnostic Uncertainty

Variability of presentationCost and invasiveness of diagnostic

modalitiesWho to screen given the low incidence

Proposed indication for Proposed indication for screeningscreening

Carotid canal fracturesNeck hematomasNeurologic deficits not explained by CT

headJournal of trauma vol 45(6) December 1998. 997-1004

Theraputic ModalitiesTheraputic Modalities

Antiplatelet therapies: ASA, PlavixHeprinization: early vs. delayedCoumadin short vs. long termSurgical repair: open vs. endovascular

techniques

Theraputic UncertaintiesTheraputic 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.

Theraputic Uncertainties Theraputic Uncertainties ContinuedContinued

No difference in early vs late heprinizationSignificant difference between treated and

untreated groupSmall number of patientsRetrospective evaluations

Theraputic Uncertainties Theraputic Uncertainties ContinuedContinued

No randomizationSingle centersUntreated group more severe injuries

precluding them from anticoagulationVol 2, 2004. Cochraine review.

Inter/ Intra Hospital TransportInter/ Intra Hospital Transport

Poor OutcomesPoor Outcomes

PICU transfers (capetown)

36% technical adverse events

27% clinical adverse events

9% critical adverse events

Occuring during interhospital trasports

Poor Outcomes ContinuedPoor Outcomes Continued

University of Pennsylvania CVA patientsIncreased odds of mortality and adverse

events during the transport, increased length of stay. esp. in age>85 years

Archives of physical medicine and Rehabilitation 84(5); 712-8. May2003

Poor Outcomes ContinuedPoor Outcomes Continued

Sydney# of transfers intrahospital is directly

proportional to the length of stay (?causal)

ParisTransfers directly proportional to risk of

nosocomial infections by a factor of 4Australian Health review 25(2); 145-54. 2002.

Consideration in our Patient/ Consideration in our Patient/ Patient UpdatePatient Update

UpdateUpdate

Family meeting with a multidisciplinary team; decision was made to withdraw care

D/C ventilator and iv hydration Morphine drip startedPatient died 5 days later

Etiology?Etiology?

AthrosclerosisHypotentionVertebral artery injury?

Would we do anything Would we do anything differently?differently?

ConclusionConclusion

Case presentationVascular injuries Transport of patients