Vascular
90% of carotid injuries stem from penetrating trauma which can lead to vascular transection, puncture wounds, or pseudoaneurysms. Suspicion for a penetrating wound is divided into hard vs soft signs. Hard signs are associated with life-threatening injuries and require immediate surgical consultation. Which of the following is a soft sign of penetrating neck injury?
a) severe, uncontrolled hemorrhage
b) small, nonexpanding hematoma
c) refractory shock/hypotension
d) neurologic deficit consistent with stroke
b) small, nonexpanding hematoma
The remainder of answers are all hard signs of penetrating neck injury.
Which of the following symptoms is most convincing for a pharyngoesophageal penetrating injury?
a) air leaking from wound site
b) hematemesis
c) blood in saliva
d) dyspnea
a) air leaking from wound site
Odynophagia, dysphagia, and gas in the deep soft tissue are also indicators for esophageal injury.
Which of the following is less likely a clinical feature of a blunt trauma laryngotracheal injury?
a) dyspnea
b) subcutaneous emphysema
c) tracheal deviation
d) dysphonia
d) dysphonia
Dysphonia is more sensitive for a penetrating injury.
Which of the following injuries is the main cause of death in patients with near death hangings?
a) compression of airway from the noose
b) hypoxic brain injury
c) pressure on carotid body leading to dysrhythmias
d) pulmonary edema
b) hypoxic brain injury
The tightening of the noose applies pressure on/compressess the vasculature supplying the brain, leading to hypoxic-ischemic brain injury.
Assuming the patient is hemodynamically stable, which of the following imaging modalities is best for identifying penetrating and blunt injuries?
a) penetrating - CT, blunt - CTA
b) penetrating - CTA, blunt - CTA
c) penetrating - DSA, blunt - CTA
d) penetrating - CTA, blunt - DSA
d) penetrating - CTA, blunt - DSA
CTA in penetrating injuries has a sensitivitiy of 90-100%
Digital subtraction angiography (DSA) is the gold standard for identifying blunt cerebrovascular injuries with a sensitivity of 97%. The sensitivity of CTA scanners vary depending on the generation of the scanner, ranging from 47% -52% for older models and 68-100% if 16-slice or better scanners are used.
What imaging modality is preferred for penetrating and blunt pharyngoesophageal injuries?
a) penetrating - CTA, blunt - swallow study
b) penetrating - CTA, blunt - CTA
c) penetrating - swallow study, blunt - endoscopy
d) penetrating - endoscopy, blunt - CTA
b) penetrating - CTA, blunt - CTA
CTA is the first choice study for both penetrating and blunt pharyngoesophageal injuries. For penetrating injuries, a CTA plus CT esophagography can be done concurrently to have a sensitivity of 100%. For blunt trauma where the CTA is inconclusive, endoscopy can be done to look for perforation.
CTA is the first line imaging modality for both penetrating and blunt injuries. Which of the following can supplement CTA findings if the CTA alone is inconclusive?
a) laryngoscopy
b) DSA
c) MRI
d) repeat CTA
a) laryngoscopy
This can be used to directly visualize the airway while intubating if there is no significant airway edema, blood or debris that is occluding the view.
Which of the following investigations is not typically part of the investigations for hanging?
a) MRI c-spine
b) MRI brain
c) echocardiography
d) chest imaging
a) MRI c-spine
CTA is the first line for evaluating strangulation injuries in the neck.
MRI brain is for ischemic brain injury. Echo to detect stressed-induced cardiomyopathy. Chest imaging for pulmonary edema.
The Biffl Scale Grading is a system that helps guide treatment of BCVI and goes from grade 1-5. Which of the following management is INCORRECTLY paired with the grade of injury?
a) grade 1 (intimal injury) - anticoagulation or antiplatelet therapy
b) grade 2 (dissection with intimal flap causing luminal narrowing <25%) - possible endovascular repair otherwise antiplatelet or anticoagulation
c) grade 3 (pseudoaneurysm) - endovascular repair plus antiplatelet or anticoagulation
d) grade 5 (vessel transection) - immediate endovascular intervention
c) grade 3 (pseudoaneurysm) - endovascular repair plus antiplatelet or anticoagulation
Endovascular repair is only required if the patient is symptomatic
Which of the following steps in management is incorrect?
a) broad-spectrum antibiotics in all cases
b) immediate surgical intervention for small and contained perforations
c) immediate surgical intervention for injuries >2cm in length
d) NG insertion under endoscopic guidance prior to any operation
b) surgical intervention for small and contained perforations
If a patient is hemodynamically stable with no signs of sepsis and a swallow study that shows contained extravasation can be monitored and does not require surgical intervention.
Regardless of whether the injury is penetrating or blunt, everybody with a pharyngoesophageal injury should be started on broad spectrum antibiotics, NPO, and insertion of an NG tube may reduce the risk of gastric contents spilling into the wound
Airway obstruction from blood, airway edema, or compression by a large hematoma or massive amounts of subcutaneous air makes stabilizing the airway the utmost priority in any neck injury. Which of the following is contraindicated?
a) Orotracheal intubation
b) surgical airway
c) intubation directly through the wound
d) noninvasie PPV
d) noninvasive PPV
This can worsen a pneumothorax or subcutaneous emphysema which can further distort the airway anatomy.
Airway collapse is very risky in laryngotracheal injuries due to the cricoid cartilage being the only complete circumferential ring stenting the larynx open.
What is the best way to treat hypoxic brain injury due to strangulation?
a) mild hypothermia
b) there are no universal guidelines available
c) thrombolysis to avoid carotid injury related stroke
d) a and c
b) there are no universal guidelines available
Some cases studies and small scale studies have shown survival benefit for mild hypothermia and thrombolysis to avoid strokes but not enough research has been done to produce reliable guidelines that can be applied universally.
There are several screening tools for blunt cerebrovascular injury, one of which is the modified Denver Criteria. Which of the following is NOT part of the modified Denver Criteria?
a) LeFort II or II fracture
b) arterial hemorrhage from neck, nose or mouth
c) air bubbling through wound
d) focal neurologic deficits concerning for TIA, stroke, or Horner syndrome
c) air bubbling through wound
This is a hard sign for penetrating injury
The probability of BCVI based on the Denver scoring is:
- 0 = 20%
- 1 = 33-48%
- 2 = 56-64%
- 3 = 80-88%
- 4 = 93%
What is the risk of mortality in blunt pharyngoesophageal injuries?
a) 15%
b) 20%
c) 35%
d) 40%
b) 20%
Since the risk of mortality is so high, these patients often require admission
Laryngotracheal injuries are graded 1-5 based on the Schaefer-Fuhrman Classification, which helps guide management. Which of the following is incorrect?
a) grade 2 injuries have moderate edema, hematoma or laceration without exposed cartilage and there is partial airway compromise
b) grade 4 injuries always require tracheostomy
c) grade 3 injuries always require tracheostomy
d) grade 5 injuries have complete laryngotracheal separation
c) grade 3 injuries always require tracheostomy
Grade 3 injuries have massive laryngeal edema, large mucosal lacerations, exposed cartilage, displaced fracture, or vocal cord immobility with associated airway compromise. These injuries frequently require a tracheostomy, but not always
Provide one mechanism for how pulmonary edema occurs in hanging cases.
1) centrally mediated neurogenic pulmonary edema - CNS insult leads to large release of catecholamines that cause cardiopulmonary dysfunction
2) post obstructive from negative intrapleural pressure generated by forceful inspiratory effort against extrathoracic obstruction. This causes increased venous return, decreased cardiac output, and leaking into the alveolar space
3) cardiogenic pulmonary edema - changes in Starling forces causes increased pulmonary venous pressure which causes elevated capillary pressures leading to fluid in the aveoli.