Morning Report: 07/25/2013

Today’s Morning Report is courtesy of Dr. Melton!

Case:

A 53 YOM BIBEMS in cervical spine precautions after being rear-ended in a motor vehicle collision. He complains of mild lateral neck pain from the seatbelt and tingling in his right arm, no midline tenderness, exam also remarkable for ecchymosis over the lateral neck.

Neck trauma + Neurologic symptoms = Carotid Artery Dissection!

Unilateral anterior neck pain or headache around the eye or frontal area, classically abrupt in onset
Findings include ipsilateral Horner syndrome, contralateral stroke, or TIA symptoms.

Symptoms are often vague and non-specific making the diagnosis challenging.

Ninety-three percent of lesions occur at the bifurcation of carotids or higher.

25%-50% of patients have no external signs of neck trauma.

Delayed neurologic deficits are the rule rather than the exception. More than 90% of patients are asymptomatic from hours to weeks after the injury; however, 10% of patients experience a transient ischemic attack or cerebrovascular accident within one hour, and 17% develop symptoms days to weeks post-injury.

Neurologic findings not explained with head CT, monoparesis or hemiparesis with normal mental status should prompt more investigation.

Patients with altered mental status who have either significant external cervical trauma or basilar skull fracture should also be studied.

Other ABEM tested neck trauma diagnosis to be familiar with:

Laryngotracheal injuries
Penetrating neck trauma
Vascular injuries
Carotid artery and Vertebral artery
Jugular vein

References:

Perina DG, Brunett P, Caro DA, Char DM, Chisholm CD, Counselman FL, Heidt J, Keim SM, Ma OJ; for the 2011 EM Model Review Task Force, The 2011 model of the clinical practice of emergency medicine, Acad Emerg Med. 2012; doi: 10.1111/j.1553-2712.2012.01385.x [Epub ahead of print]

Schaider Jeffrey, Bailitz John. Neck Trauma: Don’t Put Your Neck on the Line. Emergency Medicine Practice. July 2003.

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