CIRCULATION
Tracheostomy is the procedure of choice in the patient with laryngotracheal separation.
If the patient remains unstable after appropriate volume resuscitation, he or she should be taken rapidly to the operating room (OR) for operative control of the bleeding. If injury to the subclavian vessels is suspected, IV access should be obtained in the opposite extremity, or more appropriately in the lower extremities. If a hemopneumothorax is suspected and central venous access is necessary, a femoral line is the first option, followed by placement of the access on the side ipsilateral to the “dropped lung” (because the patient doesn’t like it when both lungs are down!).
HIGH-YIELD FACTS
Secondary Survey
Control of hemorrhage in the ED is via direct pressure (no blind clamping).
Never blindly probe a neck wound, as this may lead to bleeding in a previously tamponaded wound.
After stabilization, the wound should be carefully examined. Obtain soft-tissue films of the neck for clues to the presence of a softtissue hematoma and subcutaneous emphysema, and a chest x-ray (CXR) for possible hemopneumothorax. Surgical exploration is indicated for: Expanding hematoma Subcutaneous emphysema Tracheal deviation Change in voice quality Air bubbling through the wound Pulses should be palpated to identify deficits and thrills and auscultated for bruits. A neurologic exam should be performed to identify brachial plexus and/or central nervous system deficits as well as Horner’s syndrome.
Management
Trauma
Zone II injuries are taken to the OR for exploration. Injuries to zones I and III may be taken to the OR or managed conservatively using a combination of angiography, bronchoscopy, esophagoscopy, gastrografin or barium studies, and CT scanning.
䉴 S P I NAL T R AU MA
General
Patients on a backboard for a prolonged period of time are at risk for the formation of pressure ulcers.
Spinal trauma may involve injury to the spinal column, spinal cord, or both. Over 50% of spinal injuries occur in the cervical spine, with the remainder being divided between the thoracic spine, the thoracolumbar junction, and the lumbosacral region. As long as the spine is appropriately immobilized, evaluation for spinal injury may be deferred until the patient is stabilized.
Anatomy
60
There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae.