Asphyxiation: a review

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Asphyxiation a review

• Claire Richards and Daniel N Wallis
• Trauma 2005737-45
• Intern ???

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Traumatic asphyxia
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Incidence and Etiology

• Traumatic asphyxia is a rare condition when
  considering the numbers of major trauma victims
  seen in emergency departments, although this may
  be because many cases are unrecognized or
  unreported.
• Laird and Borman found only seven cased out of
  107000 hospital and clinic patients in a 30-month
  period, of whom 75000 had been involed in major
  accidents.(1930)
• Dwek reported only one case out of a total of
  18500 accident victims in an area with heavy
  military traffic. (1946)

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Incidence and Etiology

• A heavy load to the thoracoabdominal region, such
  as being pinned or crushed by a vehicle or piece
  of heavy machinery is the commonest cause.
• In 35 cases of traumatic asphyxia seen over a
  5-year period in New Mexico, 14(40) were due to
  road traffic accidents where the patient was
  ejected from the vehicle and then crushed as it
  rolled over them.
• The syndrome has also been described following
  unsuccessful suicide attempts by hanging, blast
  injury, asthma attack, diving, epileptic
  seizures, violent vomiting and difficult
  obstetric delivery.

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Incidence and Etiology

• In experiments on guinea pigs and dogs the
  incidence of death due to traumatic asphyxia is a
  function of absolute weight and duration of
  compression.
• There is great variation in the amount and
  duration of application of force required to
  produce the characteristic featured of this
  condition, and in some cases to cause death.
• Death in cases of prolonged compression is
  presumably caused by hypoxic cardiac arrest due
  to complete restriction of respiratory movements.

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Clinical features

• The skin of the face, neck and upper torso may
  appear blue-red to blue-black but it blanches.
• The discolouration and petechiae are often more
  pronounced on the eyelids, nose and lips.
• These petechiae also usually blanch, and increase
  in intensity in the first few hours but then fade
  over days to weeks.
• The subconjunctival hemorrhage, which almost
  always occurs, and is considered to be due to the
  relative lack of tissue support around this area,
  fades slowly and disappears.

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Clinical features

• Exophthalmos occurs in 20 of cases and this also
  slowly resolves fully.
• There may be periorbital edema and ecchymosis.
• Other mucous membranes that lack tissue support
  such as the buccal mucosa, undersurface of the
  tongue, palate and pharynx commonly show
  petechiae or ecchymoses.
• Epistaxis is often present and hemotympanum has
  also been described.
• Associated injuries include pulmonary, cardiac,
  neurological, ophthalmic, abdominal and
  orthopaedic injury.

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Clinical features

• Pulmonary injuries are those most commonly
  associated with traumatic asphyxia and are the
  most serious, including pulmonary contusion,
  pneumo-and/or hemothorax and lung lacerations.
• The most common neurological consequences are
  transient loss of consciousness and confusion,
  which may be prolonged but are generally
  self-limiting. There may also be agitation,
  disorientation and restlessness.

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Clinical features

• Abdominal injuries include liver and/or splenic
  lacerations and gastrointestinal hemorrhage due
  to blunt abdominal trauma. Diaphragmatic rupture
  is another complication that has been described.
• Transient microscopic hematuria and proteinuria
  may occur due to increased venous pressure in the
  kidneys.
• Orthopaedic injuries include fracture of the
  clavicle, long bones, pelvis and vertebrae.

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Differential diagnosis

• The diagnosis of traumatic asphyxia syndrome is
  usually evident, based on history and the
  striking characteristic clinical features.
• However, features of SVC obstruction and basilar
  skull fracture closely resemble the appearances
  of traumatic asphyxia, in particular the
  subconjunctival hemorrhages, periorbital
  ecchymosis, epistaxis and hemotympanum.

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Differential diagnosis

• However, the history of traumatic injury would
  rule out SVC obstruction, and skull fractures are
  very rare in traumatic saphyxia because the force
  of compression is not applied to the head.
• In addition, the venous pressure in the head and
  neck is normal in traumatic asphyxia after
  thoracic compression has been relieved, in
  contrast to patients with SVC obstruction.

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Treatment

• Management of these patient is supportive, and
  treatment is aimed at associated injury.
• The mainstay of treatment is oxygenation, and
  elevation of the head of the bed to 30?once the
  spine has been cleared of injury.
• Oxygen has almost no effect, however. On the
  resolution of the facial discoloration.
• Patients should be admitted initially to an ICU
  for observation.

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Treatment

• Supportive ventilation may be required of there
  is significant underlying pulmonary injury, chest
  wall damage or respiratory depression due to
  cerebral hypoxia.
• If a significant crush injury has been sustained,
  treatment with fluids, mannitol and bicarbonate
  must be given as necessary to prevent renal
  failure secondary to rhabdomyolysis.
• Since the probability of associated injury is
  high, the physical assessment of the patient must
  be thorough, if other injuries are not to be
  missed with potentially disastrous consequences.

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Thanks for your attention!
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Prognosis

• Long-term follow-up of patients who have survived
  traumatic asphyxia shows there are no long-term
  sequelae from the condition itself morbidity and
  mortality are from associated injuries.
• There are determined by the severity, nature and
  duration of the compressive force.
• The prognosis of those with traumatic asphyxia
  alone is excellent if the patient survives to
  reach the emergency department, despite their
  rather startling appearance.
• Approximately 90 of patients without associated
  injury and surviving one hour after crush injury
  will recover.