I ran over my own face

1
I ran over my own face

• Raj Upadhyay
• R3 CCFP/EM

2
Urgence Sante

• 77 M, found conscious under his car
• Has multiple lacerations and bleeds on his face
• 2143 -- 140/80, RR 20, P84, 100 on 15L
• Arrives in ER 2214

3
Pt. is in the Trauma Bay
4
Airway Assessment

• Pt having difficulty speaking
• blood in the mouth
• Significant facial trauma looks swollen and
  deformed

5
Airway Assessment Continued

• No subcutaneous emphysema
• No obvious laryngeal trauma
• Trachaea midline
• Short fat neck, small mouth

6
Airway Management

• Blood suctioned with no avail
• RSI --Etomidate 30 Succinylcholine 100
• Relatively difficult intubation
• Tube placement confirmed by qualitative CO2
  detector and auscultation

7
Breathing Assesment

• Good A/E bilaterally
• O2 sats 100 on FiO2 of 50
• Remainder unremarkable

8
Circulation Assesment

• BP now 183/72
• P 80
• Good peripheral circulation
• Other than the face, no obvious source of bleeding

9
Disability

• Difficulty opening his eyes secondary to swelling
• Difficulty talking
• Initially and may have been confused in the
  ambulance
• Overall GCS 14-15/15

10
Exposure

• Left scalp hematoma
• Bilateral periorbital ecchymosis
• Multiple lacerations around the lips, chin, and
  forehead oozing significant quantity of blood
• Abrasions and lacerations on both hands and feet

11
Adjuncts

• Foley and NGT inserted
• Fast ultrasound normal
• CXR widened mediastinum with no
  hemo/pneumo-thorax
• ETT placement appropriate

12
Secondary Survey

• Hyphema of left eye with upper and lower lid
  hematoma
• Laceration of lt medial canthus no obvious
  corneal lacerations

13
Secondary 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

14
Secondary Survey Continued

• Step deformity in the lt zygoma
• Nil in neck, chest, abdo, pelvis
• No step-deformities in TLS spines
• No blood in the rectum

15
AMPLE

• Paramedics have some of his pills that his
  frantic wife handed to them
• Coumadin, altace, diltiazam, HCTZ

16
Ample Continued

• No known allergies
• History of high blood pressure and some strokes
  in the past
• Last meal supper that night
• Significant ETOH abuse

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Event History
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Further Investigations/ Management??
19
Bleed and Infection control

• Vit K
• FFP
• Td
• Ancef
• Cocktail of shame

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CT Head

• No acute injury
• Chronic ischemic changes
• Atrophic temporal lobe
• Lacune left thalamus
• Old left and right cerebellar infarcts

21
CT Scan of Facial Bones

• Left eye blowout
• Lt zygoma
• Very displaced bilateral maxillary wall
• Ruptured left globe with air in the orbits
• Masserated left lateral and medial recti muscles
• Bilateral nasal bones

22
Radiologic Evaluation Continued

• CT chest Small lung contusions bilaterally,
  otherwise normal
• CT abdomen normal
• CT C-spine normal

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Now What?
24
Plastics

• Sutured some of the facial lacerations
• Other lacerations not amenable to suturing
  because of significant progression of swelling
• Needs ORIF in a few days when stabilized

25
Optho

• Exploration of the left globe the same night
• Left lateral canthotomy
• No rupture found

26
Trauma

• Suggested admission to ICU
• Will follow

27
Course in Hospital
28
PTD1

• Continued bleeding from the mouth overnight, 1-2
  L of blood suctioned
• Transfused 6U PRBC and 12U FFP
• Continued bleeding despite normalization of
  coagulation
• Sedated on Propafol, morphine throughout GCS E
  V1T M6

29
PTD1 Continued

• Face swollen 2 times its original size
• BP 150-190 systolic, no significant tachy
• ? Options to control bleeding?

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PTD1 Continued

• Nipride drip started to control BP
• Sent to angio to embolize the bleeding vessels
  Sphenopalatine arteries embolized bilaterally

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PTD1 Continued

• In the angio-suite BP dropped to 50 systolic and
  remained there for 15-20 minutes
• Finally restored after 1 dose of neosynephrine

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PTD2

• Plastics requests clearance of C-spine prior to
  OR
• Fluids 13L positive balance
• Diuresed for CHF on CXR
• Pt taken for tracheostomy

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Neurologic Exam

• GCS 3T ? 5T (V1T, E3, M1) when off sedation
• Bilateral flaccid paralysis
• No lateral movement of the eyelids
• ?Obeying commands to open and close the eyes.

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? DDx for Neurologic Deterioration?
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DDx

• 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

36
DDx cont..

• Neuromuscular junction delayed neuromuscular
  blockade, myesthenia gravis
• Skeletal muscles hyperkalemia, hypophosphatemia
  or hypomagnesemia, critical illness myopathy,
  acute alcoholic myopathy

37
Workup

• Normal CBC, electrolytes, Ca, Mg, PO4, LFT
  stable BUN/ Cr
• MRI of head new large pontine infarction
• CTA neck bilateral athrosclerotic stenosis is
  ICA, Normal Rt vertebral artery and opacification
  of Lt vertebral artery from C3 up

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Vascular trauma in the neck
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Intro

• BVI of neck are potentially the most devastating
  and underdiagnosed injuries seen following
  stabilization of a polytrauma patient
• Commonly associated with other confounding
  injuries

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Associated Injuries

• Closed head injuries
• Facial fractures
• Basal skull fractures through carotid foramen
• Upper thoracic fractures
• C-spine injuries

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Mechanism 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

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Incidence

• No large population based studies are available
• Several large level 1 trauma centers report
  detection rate lt1 of all blunt trauma patients

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Incidence

• Increasing incidence seen in recent years because
  of more aggressive investigation attempts.
• 80 ICA20 vertebral artery

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Diagnostic Modalities

• Angiogram gold standard
• CTA improving technology/ sensitivity rates
  described gt90
• MRA may define other associated injuries and
  more detailed description of resultant and
  concominant brain pathology

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Diagnostic Uncertainty

• Variability of presentation
• Cost and invasiveness of diagnostic modalities
• Who to screen given the low incidence

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Proposed indication for screening

• Carotid canal fractures
• Neck hematomas
• Neurologic deficits not explained by CT head
• Journal of trauma vol 45(6) December 1998.
  997-1004

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Theraputic Modalities

• Antiplatelet therapies ASA, Plavix
• Heprinization early vs. delayed
• Coumadin short vs. long term
• Surgical repair open vs. endovascular techniques

48
Theraputic 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.

49
Theraputic Uncertainties Continued

• No difference in early vs late heprinization
• Significant difference between treated and
  untreated group
• Small number of patients
• Retrospective evaluations

50
Theraputic Uncertainties Continued

• No randomization
• Single centers
• Untreated group more severe injuries precluding
  them from anticoagulation
• Vol 2, 2004. Cochraine review.

51
Inter/ Intra Hospital Transport
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Poor Outcomes

• PICU transfers (capetown)
• 36 technical adverse events
• 27 clinical adverse events
• 9 critical adverse events
• Occuring during interhospital trasports

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Poor Outcomes Continued

• University of Pennsylvania
• CVA patients
• Increased odds of mortality and adverse events
  during the transport, increased length of stay.
  esp. in agegt85 years
• Archives of physical medicine and Rehabilitation
  84(5) 712-8. May2003

54
Poor Outcomes Continued

• Sydney
• of transfers intrahospital is directly
  proportional to the length of stay (?causal)
• Paris
• Transfers directly proportional to risk of
  nosocomial infections by a factor of 4
• Australian Health review 25(2) 145-54. 2002.

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Consideration in our Patient/ Patient Update
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Update

• Family meeting with a multidisciplinary team
  decision was made to withdraw care
• D/C ventilator and iv hydration
• Morphine drip started
• Patient died 5 days later

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Etiology?

• Athrosclerosis
• Hypotention
• Vertebral artery injury?

58
Would we do anything differently?
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Conclusion

• Case presentation
• Vascular injuries
• Transport of patients