Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
Resuscitate with blood products -> Activate massive transfusion protocol
If you have fiber optics and the skill for it – go for it
If blood in airway -> direct laryngoscopy
Have backups in place and be prepared for surgical airway
Signs Management Algorithm
Hard signs – Patient needs to go to the OR
Soft Signs – need CT angiography.
Role of C-collars in penetrating trauma
Probably not necessary
The advantage of the collar is protecting patient with unstable C-spine injury (based on literature its a low occurrence)
The disadvantage of the collar is you’re now limiting a more thorough exam, could be obstructing the extent of the wound, ifbleeding wont be able to apply pressure and airway management with collar is significantly more difficult.
CAVEATS
If altered mental status – keep the collar on
If neurologic deficit – keep collar on
Zones of the Neck
Zone 1 – area between the clavicles and the cricoid cartilage
Contains the innominate vessels, the origin of the common carotid artery, the subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the esophagus, the apex of the lung, and the thoracic duct
Zone 2 – area between the cricoidcartilage and the angle of the mandible.
Contains the carotid and vertebral arteries, the internal jugular veins, trachea, and esophagus.
Zone 3 – area between the angle of the mandible and the base of the skull.
Contains the distal carotid and vertebral arteries and the pharynx.
In practice, it’s not all that important to know the different zones
Zone 2 injury used to be immediate OR indication. However studies have not borne that out and now patients can undergo imaging if no hard signs.
When it may come into play is once you’ve diagnosed particular vascular / organ injury depending on what zone the injury is it could affect surgical intervention.
What to do if injury involves pulsatile bleeding
Apply direct pressure to the wound / bleeding site.
Get IV access, give oxygen, prepare to take the airway and get blood products
If at trauma center-> get your trauma surgeon
If community / rural -> stabilize and transfer
Blood products means starting massive transfusion protocol.
Resources:
EM: RAP: Penetrating Neck Trauma Part 1 and Part 2