Rosen & Barkin's 5-Minute Emergency Medicine Consult (474 page)
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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen
Tags: #Medical, #Emergency Medicine
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Imaging
TREATMENT
PRE HOSPITAL
Admission Criteria
CODES
ICD9
Adam Z. Barkin
BASICS
DESCRIPTION
- Lateral neck radiograph to evaluate soft tissue injury and detect foreign bodies
- Chest radiograph to detect hemopneumothorax, mediastinal air
- Zone I:
- Angiography: Gold standard to evaluate vessel injury, invasive
- Helical CT angiography: Speed, noninvasive
- Aware of streak artifact from shoulder, poor view of subclavian vessels
- Aware of streak artifact from shoulder, poor view of subclavian vessels
- Esophagram with water soluble contrast or dilute barium:
- Low sensitivity
- Combine with esophagoscopy to exclude injury.
- Indications: Wound approaches/crosses midline, SC air
- Low sensitivity
- Angiography: Gold standard to evaluate vessel injury, invasive
- Zone II:
- Asymptomatic: Observation
- Symptomatic: OR
- Asymptomatic: Observation
- Zone III:
- Symptomatic: Angiography or CT angiogram
- Symptomatic: Angiography or CT angiogram
- Bronchoscopy can be helpful in evaluating tracheal injury.
- Surgical consult for all wounds that penetrate platysma muscle
- Surgical exploration:
- Expanding or pulsatile hematoma
- Active bleeding
- Absence of peripheral pulses
- Hemoptysis
- Horner's syndrome
- Bruit
- SC emphysema
- Respiratory distress
- Air bubbling through wound
- Expanding or pulsatile hematoma
- Surgical exploration:
- Peripheral or CNS injury
- Cervical spine injury
- Associated head or thoracic trauma
TREATMENTPRE HOSPITAL
- Frequent suctioning to clear airway of blood, secretions, or vomitus
- 2 large-bore IVs
- High-flow O
2
should be provided - BVM should be avoided for potential distortion of neck anatomy and airway compromise due to forced air through tracheolaryngeal wound into tissues
- Airway must be vigilantly monitored, as edema or expanding hematoma can progress to airway compromise.
- Indications for early oral intubation:
- Clinical signs of respiratory distress
- Stridor
- Air hunger
- Labored breathing
- Expanding neck hematoma
- Clinical signs of respiratory distress
- Nasotracheal intubation has not been proven to worsen penetrating wounds
ALERT
INITIAL STABILIZATION/THERAPY- Occlusive dressings should be applied to lacerations over major veins to prevent air embolism.
- Cervical spine immobilization in the absence of focal neurologic deficits is not indicated
- Blocks direct visualization/palpation of neck; increases likelihood of missing life-threatening signs
- Blocks direct visualization/palpation of neck; increases likelihood of missing life-threatening signs
- Emergent intubation is indicated:
- Patients who are in respiratory distress or comatose.
- Be aware of voice change or odynophagia
- Patients who are stable without evidence of respiratory distress may be managed aggressively with prophylactic intubation or observed closely with airway equipment at bedside.
- Orotracheal intubation with rapid-sequence induction is method of choice for securing airway in penetrating neck trauma.
- Blind nasotracheal intubation is contraindicated with apnea, severe facial injury, or airway distortion.
- Fiberoptic bronchoscopic intubation is advantageous as patient may stay awake, allows direct visualization of vocal cords and injuries.
- Percutaneous transtracheal ventilation may be useful when oral or nasotracheal intubation fails:
- This is contraindicated in cases of upper airway obstruction.
- May cause barotrauma
- This is contraindicated in cases of upper airway obstruction.
- Cricothyroidotomy contraindicated if significant hematoma overlying cricothyroid membrane
- Tracheostomy is warranted in this setting
- Tracheostomy is warranted in this setting
- Breathing:
- Zone I injury can cause pneumothorax or subclavian vein injury and hemothorax:
- May require needle decompression and tube thoracostomy
- May require needle decompression and tube thoracostomy
- Patients who are in respiratory distress or comatose.
- Circulation:
- External hemorrhage:
- Control with direct pressure.
- If failed, insert and inflate Foley catheter balloon within wound to tamponade bleeding
- Blind clamping of vessels is contraindicated owing to risk of further neurovascular injury.
- Control with direct pressure.
- Uncontrolled bleeding or hemodynamic instability: Send directly to OR.
- After intubation, throat can be packed with heavy gauze to tamponade bleeding.
- Hemothorax: Tube thoracostomy
- External hemorrhage:
- Nasogastric tube should
not
be placed because of risk of rupturing pharyngeal hematoma. - Prophylactic antibiotics are recommended (cefoxitin, clindamycin, penicillin G + metronidazole).
- Tetanus prophylaxis
- Cefoxitin: 2 g (peds: 80–160 mg/kg/d div. q6h) IV q8h
or - Clindamycin: 600–900 mg (peds: 25–40 mg/kg/d div. q6–8h) IV q8h
or - Penicillin G: 2.4 million U/d (peds: 150,000–250,000 U/kg/d) IV q4–6h, + metronidazole
- Metronidazole: 1 g load, then 500 mg (peds: 30 mg/kg/d div. q12h) IV q6h
Admission Criteria
- All patients with penetrating neck trauma should be admitted and observed for at least 24 hr.
- Observation must take place in facility capable of providing definitive surgical care.
- Patients with injuries suggesting airway or vascular injury must be admitted to ICU.
- Asymptomatic patients who have negative studies may be discharged after 24 hr of observation.
- Patients with wounds superficial to the platysma may be discharged directly from the ED
- Failure to anticipate difficulties in airway management
- Failure to recognize impending airway compromise
- Múnera F, Cohn S, Rivas LA. Penetrating injuries of the neck: Use of helical computed tomographic angiography.
J Trauma
. 2005;58(2):413–418. - Ramasamy A, Midwinter M, Mahoney P, et al. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma.
Injury
. 2009;40(12):1342–1345. - Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: Penetrating zone II neck trauma.
J Trauma
. 2008;64(5):1392–1405. - Woo K, Magner DP, Wilson MT, et al. CT angiography in penetrating neck trauma reduces the need for operative neck exploration.
Am Surg
. 2005;71(9):754–758. - Wolfson AB.
Harwood-Nuss’ Clinical Practice of Emergency Medicine
. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
CODESICD9
- 874.01 Open wound of larynx, without mention of complication
- 874.8 Open wound of other and unspecified parts of neck, without mention of complication
- 874.9 Open wound of other and unspecified parts of neck, complicated
ICD10
NECROTIZING SOFT TISSUE INFECTIONS- S11.011A Laceration without foreign body of larynx, initial encounter
- S11.81XA Laceration w/o foreign body of oth part of neck, init encntr
- S11.90XA Unsp open wound of unspecified part of neck, init encntr
Adam Z. Barkin
BASICSDESCRIPTION
- Necrotizing soft tissue infections (NSTI) are infections of any layer of the skin associated with necrotizing changes
- Usually spreads rapidly along tissue planes
- Usually spreads rapidly along tissue planes
- Characterized by:
- Widespread fascial and muscle necrosis with relative sparing of the skin
- High mortality
- Systemic toxicity
- Widespread fascial and muscle necrosis with relative sparing of the skin
- Crepitant anaerobic cellulitis:
- Necrotic soft tissue infection with abundant connective tissue gas
- Necrotic soft tissue infection with abundant connective tissue gas
- Progressive bacterial gangrene:
- Slowly progressive erosion affecting the total thickness of skin but not involving deep fascia
- Slowly progressive erosion affecting the total thickness of skin but not involving deep fascia
- Nonclostridial myonecrosis (synergistic necrotizing cellulitis):
- Aggressive soft tissue infection of skin, muscle, SC tissue, and fascia
- Aggressive soft tissue infection of skin, muscle, SC tissue, and fascia
- Fournier gangrene:
- Mixed aerobic–anaerobic soft tissue necrotizing fasciitis of the skin of the scrotum and penis in men and the vulvar and perianal skin in women
- Mixed aerobic–anaerobic soft tissue necrotizing fasciitis of the skin of the scrotum and penis in men and the vulvar and perianal skin in women
- Necrotizing fasciitis:
- Progressive, rapidly spreading infection with extensive dissection and necrosis of the superficial and deep fascia
- Progressive, rapidly spreading infection with extensive dissection and necrosis of the superficial and deep fascia
- Accounts for 500–1,500 cases per year in US
- Often difficult to recognize
- Incidence increases with:
- Age
- Smoking
- Chronic systemic disease:
- Diabetes
- Obesity
- Peripheral vascular disease
- Alcohol abuse
- IV drug use
- Diabetes
- Age
- 24–34% mortality
- Also high morbidity:
- Amputations
- Renal failure
- Amputations
- Conditions that lead to the development of NSTIs:
- Local tissue trauma with bacterial invasion
- Local ischemia and reduced host defenses:
- More frequently in diabetics, alcoholics, immunosuppressed patients, IV drug users, and patients with peripheral vascular disease
- More frequently in diabetics, alcoholics, immunosuppressed patients, IV drug users, and patients with peripheral vascular disease
- Local tissue trauma with bacterial invasion
- Type I NSTI:
- Polymicrobial
- Anaerobic and aerobic
- Include Fournier gangrene and Ludwig angina
- After surgical procedures
- Existing diabetes, peripheral vascular disease, chronic kidney disease, alcohol abuse
- Compromised immune system
- Compromised immune system
- Represent 80% of NSTIs
- Strep species are most common aerobes
- Also staph, enterococci, and gram-negative rods
- Also staph, enterococci, and gram-negative rods
- Bacteroides are most common anaerobes
- Polymicrobial
- Type II NSTI:
- Monomicrobial
- Typically aerobic Streptococcus
- Often young, healthy patients
- Most common cause of “flesh eating” disease
- Methicillin-resistant Staphylococcus aureus (MRSA) species are becoming more common
- Monomicrobial
- Type III NSTI
- Least common NSTI (<5%)
- Rapidly progressive
- Clostridial myonecrosis is an example
- Usually following penetrating wounds or crush injuries
- Also can be seen after black tar heroin injection, skin popping, intestinal surgery, obstetrical complications
- Least common NSTI (<5%)
- Bacteria involved include:
- Group A β
2
-hemolytic streptococcus (GABHS) - Group B streptococcus
- Staphylococci
- Enterococci
- Bacillus
- Pseudomonas
- Escherichia coli
- Proteus
- Klebsiella
- Enterobacter
- Bacteroides
- Pasteurella multocida
- Clostridium sp.
- Vibrio sp.
- Aeromonas sp.
- Fungi
- Group A β
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