Craig Hore talks us through a case based discussion on trauma and CTA of the neck and thorax; and all in under 15 minutes! This talk was recorded at BCC4.

1. Hay, hay…..CTA!!*
*(Warning: bad pun)
Craig Hore
Intensive Care Unit
Liverpool Hospital

2. For the city slickers…..

3. MIST
M:
75 yr old male brought to by helicopter after
getting head trapped between tractor hydraulic
mechanism and hay bale lifting apparatus
(approx. 4 inch gap)
Previously fit and well
I:
Ü Lateral and anterior neck injuries
Ü Head injury
Ü Facial bone injuries
Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:
10.40
10.53
11.40
12.08
13.04

4. MIST
S:
Ü BP= 140/75
Ü GCS = 15
Ü RR 25
HR= 63
Sats 96%
T:
Ü Fentanyl
Ü Ondansetron
Ü Sandbags and tap (not tolerating cervical neck
collar)
Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:
10.40
10.53
11.40
12.08
13.04

5. Primary Survey
A
Ü
Patent; no stridor
Ü
Neck - sandbags and tape in situ
Ü
Expectorating blood
B
Ü
SpO2 96%
Ü
RR = 25
Ü
Trachea midline
Ü
No chest wall tenderness
Ü
Equal breath sounds bilaterally
Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:
10.40
10.53
11.40
12.08
13.04

6. Primary Survey
C
Ü
Well perfused; CRT < 2sec
Ü
PR 63 bpm BP 140/75
Ü
Pelvis stable Abdo SNT
D
Ü
GCS 15 PEARL
E
Ü
•
Logroll NAD

7. Immediate management
Ü IV access:
- Bloods taken
Ü Immobilisation
Ü O2
Ü Warming:
- Warmed IV Fluids
- Warming blanket
Ü ADT given
•

8. Secondary survey
Ü HEAD:
-
Loose teeth, bleeding from mouth
Ü NECK:
-
No central C-spine tenderness
-
Sandbags and tape
-
Bilateral swelling and ecchymoses of
the lateral neck
Ü CHEST: NAD
•

9. Secondary survey
Ü ABDO:
- SNT; normal FAST
Ü PELVIS:
- stable; plain X-ray normal
Ü LIMBS:
- NAD
Ü BACK:
- NAD
•

10. Where to next?

11. Radiology department
Ü CT BRAIN (14:50):
- no acute intracranial abnormality
Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:
10.40
10.53
11.40
12.08
13.04

12. Any other images?
Why or why not?

13. Radiology department
Ü CT CAROTID ANGIO:
Approx Injury Time:
Dispatched:
Arrive scene:
Depart:
ED:
10.40
10.53
11.40
12.08
13.04

24. Radiology department
Ü C-spine:
- non-displaced fracture through right C2 lateral mass
traversing the transverse foramen laterally
- non-displaced fracture of the base of spinous
process and a displaced fracture of transverse
process of C3 on the right side
-
non-displaced fracture of the transverse process of
C4 bilaterally traversing the transverse foramina
- fracture through the transverse foramen of C5 on
the left

25. Radiology department
Ü CT CAROTID ANGIO:
- right vertebral artery dissection

28. Any other images?

31. Radiology department
Ü C-spine MRI (17:19):
- oedema in the posterior spinal soft tissues of the mid
to upper cervical spine
- raises possibility of ligamentous injury

32. Where to next?

33. Progress
Ü Admitted to surgical ward
Ü Vascular surgery and interventional radiology
review:
- observation
- not for anti-coagulation
Ü PCA fentanyl
Ü Fax / max for mandibular fractures
Ü Neurosurgical review:
- cervical collar for six weeks

34. CTA neck - indications?

35. Screening criteria CTA Neck
(blunt CVI)
Ü Injury Mechanism:
Severe cervical hyper-extension, rotation or
hyperflexion associated with:
- displaced midface or complex mandibular
fracture
- closed head injury consistent with diffuse axonal
injury
- near hanging resulting in hypoxic brain injury

36. Screening criteria CTA Neck
(blunt CVI)
Ü Physical signs:
- seat belt abrasion
- other soft injury of anterior neck resulting in
significant swelling or altered mental status
- fracture in proximity to ICA or vertebral artery
- basilar skull fracture involving carotid canal
- cervical vertebral body fracture
Ü

37. Questions?