The devastating potential of blunt vertebral artery injuries

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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 5 • September 2001

mended. If any of the criteria were positive, then the patients underwent a lateral open mouth odontoid and an AP film of the cervical spine. All patients ultimately underwent radiographic cervical spine evaluation. The study population consisted of 34,069 patients. The authors found that the decision instrument identified all but 8 of the 818 patients who had cervical spine injury, yielding a sensitivity of 99% and a negative predictive value of 99.8%. The authors concluded that this simple decision instrument can help physicians reliably identify the patients who need radiography of the cervical spine after blunt trauma. This study is well worth reading and analyzing. It will be quoted frequently and could easily be the landmark paper to help the decision making in the emergency department.

Evaluation of the Acute Cervical Spine: A Management Algorhithm. Banit DM, Grau G, Fisher JR. J Trauma 2000;49:450456. The authors developed a new cervical spine clearance protocol, the purpose of which was to reduce the incidence of missed injuries and to maximize resource use without sacrificing quality of care. The incidence of cervical spine injuries is estimated to be 2% to 3% of all trauma patients who sustain cervical injuries. The question the authors focused on was whether the statement "asymptomatic, occult cervical spine injuries exist" is true or not. Another important point is that normal radiographs do not rule out cervical spine injury in the presence of neck pain, tenderness, or neurologic deficits. The authors developed a protocol which emphasized the importance of a normal mental status that has not in any way been altered by trauma, drugs, or alcohol. The next important element was the history of the injury. A high-energy injury is more likely to cause a cervical spine injury. The authors also emphasize the necessity for a "tertiary exam": an examination performed on a patient who is sober, without neurologic deficits, and without distracting injuries. The tertiary examination is performed after all distracting injuries are addressed and includes a thorough neurologic examination as well as a focused examination of the cervical spine for pain and tenderness, and a patient can be cleared clinically only after a normal tertiary examination. In the patient who has a normal tertiary examination but still has pain, the patient may be discharged from the hospital in an immobilization collar with a scheduled follow-up appointment to occur within 10 to 14 days, for repeat films with flexion and extension views.

C-Spine Injury Associated With Gunshot Wounds to the Head: Retrospective Study and Literature Review. Lanoix R, Grupta R, Leak L, et al. J Trauma 2000;49:860-863. This retrospective study reviewed the literature to determine the incidence of cervical spine injury associated with gunshot wounds to the head. The authors contested the "common wisdom" of maintaining cervical spine immobilization in patients who require endotracheal intubation and further diagnostic work-up. They reviewed the available literature and found that no injury to the cervical spine was discovered in patients with isolated head injury. They concluded that cervical spine immobilization and diagnostic radiography of the cervical spine are not necessary in patients with isolated gunshot wounds to the head. This conclusion is in agreement with several other studies published within the past 3 years.

VASCULAR Is Routine Arteriography Mandatory for Penetrating Injuries to Zone 1 of the Neck? Edy VA. J Trauma 2000;48:208-224. The Multi-Institutional Trial Committee of the Eastern Association for the Surgery of Trauma investigated the necessity of

arteriography in patients who had suffered penetrating injuries to zone 1 of the neck--that portion blow the cricoid. The main question was whether patients with normal findings on physical examination and on chest x-ray film really require arteriography. In 5 level I trauma centers, all patients who suffered penetrating injuries of zone 1 of the neck were retrospectively reviewed. Data collected included demographics, physical examination results, chest x-ray film findings and other diagnostic studies done. Of 138 patients studied, 36 patients had normal findings on physical examination and on chest x-ray film, and none of these had an arterial injury. A normal physical examination and chest x-ray film might be adequate justification for not performing arteriography in patients with zone l stab wounds of the neck, but further confirmation is needed.

Treatment of Posttraumatic Internal Carotid Arterial Pseudoaneurysms With Endovascular Stents. Coldwell DM, Novak Z, Ryu RK, et al. J Trauma 2000;48:470-472. The incidence of carotid artery injuries has been estimated to be from 1% to 3% of all blunt trauma victims. In a more selected cohort of patients with direct injuries to the face, lateral mandibular area, or basilar skull fracture, or a history of serious hyperextension-rotation mechanism, the incidence has been reported to be as high as 25%. The authors of this report have extensive experience and great interest in evaluating patients for carotid artery dissections. They have an aggressive investigative protocol where any patients who suffer direct blunt trauma to the neck, a basilar skull fracture, cervical spine fracture, extensive mid face trauma, or any injury to the neck with a hyperextension-rotation mechanism, are evaluated for the presence of carotid dissection through cerebral arteriography. The authors found 14 patients who suffered injuries of the carotid artery. Immediate therapy was heparin anticoagulation. After 7 days, a repeat arteriogram was performed to detect the development of a pseudoaneurysm. If one was present, they then placed a self-expanding metal stent across the neck of the aneurysm to prevent thrombosis and to establish non turbulent flow. The carotid artery was studied angiographically at a delayed time after placement of the stent. Stents reinforced the damaged wall of the artery and kept the lumen of the artery patent.

The Devastating Potential of Blunt Vertebral Artery Injuries. Biffl WL, Moore EE, Elliott JP, et al. Ann Surgery 2000;231: 672-681. This article calls the reader's attention to a previously underestimated injury which has traditionally been felt to be benign. The purpose of this study was to review the authors' experience with vertebral artery injuries and to formulate a diagnostic and therapeutic plan for them. The Denver group was very aggressive in evaluating patients for vertebral artery injuries. Four-vessel arteriography was performed for any of the following injuries suggestive of cerebral vascular arterial injury: hemorrhage from the mouth, nose, ears, or wounds of potential arterial origin, expanding cervical hematoma, cervical bruit in a patient younger than 50 years of age, evidence of cerebral infarction on computed tomography, unexplained or incongruous central or lateralizing neurologic deficit, transient ischemic attack, and amaurosis fugax or Homer's Syndrome. In addition, screening arteriography was performed in patients with injury mechanisms compatible with severe cervical hyperextension/rotation or flexion, near hanging resulting in cervical anoxia, seatbelt abrasions, or other soft tissue injury of the anterior neck resulting in significant cervical swelling or altered mental status, basilar skull fractures including the carotid canal, and cervical vertebral body fracture or dislocation. Obviously, the authors were very aggressive in their screening! Injuries to the vertebral arteries were classified by the authors' scale: grade

McCABE AND WARREN • TRAUMA: AN ANNOTATED BIBLIOGRAPHY

1, arteriographic appearance of irregularity of the vessel wall or a dissection; grade 2, intraluminal thrombus or raised intimal flap; grade 3, pseudoaneurysm; grade 4, vessel occlusion; grade 5, transection. The authors studied 7,205 trauma admissions over 2 1/2 years. Vertebral artery injuries were diagnosed by cerebral angiography in 38 patients. Cervical spine injuries were found in 27 (71%) of these patients. Patients were treated with systemic heparinization unless there was a contraindication to heparin, in which case antiplatelet agents or subcutaneous low molecular weight heparin was given. The authors found no particular injury mechanism that was distinctly at high risk for causing vertebral artery injury. They did find that cervical spine injury was the only independent risk factor for blunt vertebral artery injury. Vertebral artery injury was not benign in the authors' experience: the incidence of stroke was 24% and the overall death rate was 18%, (8% attributable to the vertebral artery injury).

Physical Examination Plus Chest Radiography in Penetrating Periclavicular Trauma: The Appropriate Trigger for Angiography. Gasparri MG, Lorelli DR, Kralovich KA, et al. J Trauma 2000;49:1029-1033. The objective of the present study was to review the recent experience with penetrating periclavicular trauma to determine the role of physical examination, chest radiography, and angiography. The periclavicular region was defined as that area between the trapezius superiorly, the second rib inferiorly, the sternum medially, and the anterior axillary line laterally. Patients with penetrating injuries to this area who presented with massive hemothorax (more than 1500 mL) and/or unstable vital signs were taken emergently to the operating room. Patients with "hard signs" of vascular injury (decreased or absent distal pulse, pulsatile hematoma, massive external hemorrhage) and stable vital signs were taken for angiography. Patients without hard signs of vascular injury underwent angiography with further intervention when required. The authors were able to show that if a patient with penetrating periclavicular injury presented without a neurologic deficit, no visible hematoma, and no hemothorax on chest radiograph, a vascular injury was excluded. Using these criteria, angiography could have been foregone in 70% of the patients without missing any injuries.

Gunshot Wounds Below the Popliteal Fossa: A Contemporary Review. Grossman MD, Reilly P, McMahan D, et al. Am Surgeon 2000;66:360-365. The aim of this report was simply to provide a database documenting what problems are caused by gunshot wounds (GSW) below the knee. The authors reviewed the charts of 100 patients with isolated infrapopliteal GSW seen over the course of 6 years. Twenty-four of the patients required angiography based on the findings of diminished pulse on physical exam and/or an anklebrachiai index of less than 0.9. Nineteen patients had positive anglos, 5 underwent embolization for bleeding, and 1 had surgical ligation. Thirteen patients had compartment syndrome. Thirty-five patients had fractures, and 10 of these 35 had associated vascular injury. No patient required vascular reconstruction, and no limb loss or death occurred.

PREGNANCY Fetal Death After Trauma in Pregnancy. Theodorou DS, Velmahos GC, Souter I, et al. Am Surgeon 2000;66:809-812. This is an important paper for all trauma caregivers to have read. The authors reviewed the charts of 80 pregnant trauma victims, and found that hemodynamic stability did not correlate with fetal mortality: 2 patients lost their fetus despite insignificant trauma,

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and 8 delivered normal babies despite major trauma (ISS -> 16). The only independent risk factors for fetal mortality were an ISS --> 9 and a nonviable pregnancy ( < 23 weeks). The conclusion is justified that close maternal and fetal monitoring is indicated regardless of maternal hemodynamic presentation and severity of injury.

PEDIATRIC TRAUMA Impact of Pediatric Trauma Centers on Mortality in a Statewide System. Potoka DA, Schail LC, Gardner MJ, et al. J Trauma 2000;49:237-245. Over 1.5 million childhood injuries occur annually, resulting in approximately 500,000 hospitalizations. Approximately 15,000 to 20,000 children die of injuries each year. There is controversy concerning where care for these injuries is best delivered. To clarify issue, the authors studied the impact of Pediatric Trauma Centers (PTC) on the outcome of injured children. The State of Pennsylvania has an extensive trauma registry which was utilized. Patients were taken to either an American College of Surgeonsdesignated pediatric trauma Center, to an adult trauma center (ATC) with added qualifications in pediatric trauma, to a level I adult trauma center, or to a level II trauma center. The majority of pediatric patients were treated at adult trauma centers with or without added qualifications. The authors were able to identify a significantly lower overall mortality rate in children treated at a pediatric trauma Center or an adult trauma center with additional qualifications. Mortality for children with head, liver, or spleen injuries were significantly lower at the pediatric trauma centers compared with the other varieties of trauma center. Because of the overwhelming numbers of pediatric injuries, not all pediatric patients can be cared for at a pediatric trauma center. It is clear from this study that patients who are more severely injured, particularly those with head injuries, have a better survival rate at a pediatric trauma center. If a hospital that is an adult trauma center develops additional qualifications and interest in caring for the pediatric trauma victim, the ultimate outcome (mortality) can be equivalent to the results in a pediatric trauma center.

Alcohol and Motor Vehicle.Related Deaths of Children as Passengers, Pedestrians and Bicyclists. Margolies LH, Foss RD, Dolbert WG. JAMA 2000;283:2245-2248.

Characteristics of Child Passenger Deaths and Injuries Involving Drinking Drivers. Qninlan KP, Brewer RD, Sleet DA, et al. JAMA, 2000;283:2249-2252.

Child Injuries and Fatalities From Alcohol-Related Motor Vehicle Crashes. Call for a 0-Tolerance Policy. Editorial. Guohua L. JAMA, 2000;283:2291-92. These 2 articles and the editorial make excellent reading for all those who are involved with the management of patients who present after alcohol-related motor vehicle crashes. The authors point out that although the number of adult deaths that have occurred from alcohol-related crashes has decreased slightly over the past few years, it is not clear that the number of pediatric deaths that occur from injuries resulting from either being struck as pedestrians or as bicyclists by alcohol-impaired vehicle operators, or being passengers in cars driven by intoxicated adults, has decreased. The authors examined the association between alcohol use by drivers and mortality to children as passengers, pedestrians, and bicyclists. In the study by Margolies, the number of alcoholrelated deaths has decreased minimally, but the impressive number was the number of drivers younger than the legal drinking age of 21 years who were the operators of the motor vehicle that resulted in the pediatric death. In the article by Quinlin, the majority of the