Its time for our next installment of Trauma Drama. I think its time to get into discrete injuries. The first one I want to talk about is blunt neck trauma. The reason I chose this one is that penetrating neck trauma gets all of the attention and gets people excited. Penetrating neck trauma is certainly more photogenic then blunt neck trauma but blunt neck trauma is more frequent and equally if not more dangerous and yet not much is written about it.
A search of blunt neck trauma was not as plentiful as would be expected and most of the information out there was case reports and stories of severe cases. For example a kid with complete transection of trachea and esophagus following a clothes line who survived. This type of case is rare and survival is poor. This is interesting considering that blunt neck injuries are as frequent as penetrating neck injuries. With the increased use of CT scans and CTAs more and more arterial and venous injuries are being found during blunt head and neck injury. With CT improvement the reliability of CTAs is increasing its uses and multiple centers are trying to come up with algorithms and scoring systems to propose its use in these situations.
In fact EAST (Eastern Association for Surgery of Trauma) recently had their guideline published in EBMedicine discussing the use of CTA for the screening and diagnosis of Blunt Cerebrovascular Injury (BCVI). There was also a paper published out of Massachusetts by Delgado Almandoz et al. in 2010 in Radiology that is suggesting the use of an acute craniocervical trauma scoring system for these patient.
The first paper I want to discuss is the Delgado Almandoz paper “Multidetector CT Angiography in the Evaluation of Acute Blunt Head and Neck Trauma: A Proposed Acute Craniocervical Trauma Scoring System.” In the study they looked at blunt head and neck injuries over a 9 year period for arterial injury. They looked at the concurrent injuries and mechanism of action and tried to extrapolate a scoring system from the results. The brief gest of the paper is that they took the Denver screening criteria and looked for a way of simplifying it with the increased use of CTA and decreased criteria. The Denver screening criteria are below:
When a patient was identified using this screening was identified they received a CT head and neck without ontrast and CTA of the head and neck. Their medical records were later reviewed for demographic data and mechanism of injury. The study found 830 patient that met the criteria. The authors then used the patients CTA results and compared them to the noncontrast CT and mechanism of injury. A 3 rule scoring system was created and a score of 1 or higher indicated a need for CTA.
Low impact MOI included: hanging/strangulation, low speed MVA, fall from standing
HIgh impact MOI included: high speed MVA, motorcycle accidents, ped or bicycle struck, fall from height greater then standing, fall down stairs, and high force blows to head or neck.
For every point their risk of positive CTA results went up 10%
The next paper is the Blunt Cerebrovascular Inury Practice Management Guidelines as proposed by the Eastern Association of the Surgery of Trauma. Their guidelines answered 3 questions on the issue and the level of evidence was identified.
What patient should be screened for blunt neck trauma/cerebrovascular injury?
Level 2:
– unexplained neurological abnormality
– espistaxis from possible arterial source following trauma
Level 3:
– Significant blunt head trauma: GCS <8, petrous bone fracture, DAI, c-spine fracture, Le Fort II or III and fracture through the foramen transversum
What is the appropriate modality for the screening and diagnosis of BCVI?
Level 2:
– Four vessel cerebral angiography is the gold standard and duplex US and 4 slice CTA or less is not appropriate
Level 3:
– CTA 8 slice or greater is comparable to angiography and can be used in place of
How should blunt neck trauma and blunt cerebrovascular injury be treated?
Their treatment recommendations are based on the grading scale as proposed by the Denver grading scale.
Level 2:
– Aspirin or Heparin should be used for grade I and II with level III evidence for the preference of heparin
Level 3:
– Grade III and above should receive surgical intervention.
After looking at these two papers I have some questions and issues. Are these injuries being missed or are the MOI seen in the above studies different then our population? Considering that our ped struck and bicycle struck are such low speed and overall the injuries are minor I do not think that these fall into major MOI. I think our location and trauma population makes these guideline and rules not a predictive of injury for Brooklyn.
But, should we be doing more CTAs of the head and neck? Do you think the EAST guidelines or the acute craniocervical trauma scoring systems are useful? Is there one that you think is better?
mritchie
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1 Comment
andygrock · May 22, 2012 at 10:14 pm
Hi Ya’ll. Just wanted to thank Dr. M Ritchie for a great review. I think that a lot of bicycle falls I have seen here have been extremely minor and do not need CTA’s. I can’t say exactly what “low MOI” is exactly. One of those, hard to describe, but know it when you see it sort of things.
Low or High MOI, I would definitely CTA anyone who has any of the other criteria on either guidelines though.
For those of you out there thirsting for more knowledge, there is a (much more poorly written of course) ebm on carotid dissections – april 2012 edition. Another topic from the ebm by the way: spontaneous carotid artery dissection. Yes it can happen spontaneously – have you asked your patient’s lately if they have hyperhomocysteinemia?