Neck injuries from trauma can be life-threatening due to the important structures in the neck. A systematic approach is needed to evaluate and manage neck injuries. It is important to understand the neck anatomy, which can be divided into zones. Zone 1 injuries carry the highest risk and mortality. Common injuries include fractures to laryngeal cartilage and soft tissue injuries. Injuries are evaluated with imaging and laryngoscopy. Management depends on injury severity and may involve airway support, antibiotics, steroids, or surgery to repair damaged structures.
neck trauma
for emergency medicine resident training
penetrating neck trauma
blunt neck trauma
strangulation neck trauma
airway management
how to deal
three zone
no zone strategy
neck trauma
for emergency medicine resident training
penetrating neck trauma
blunt neck trauma
strangulation neck trauma
airway management
how to deal
three zone
no zone strategy
Tips, Pearls and Pitfalls of Spinal Cord MRIWafik Bahnasy
- Many neurological disorders simultaneously or consecutively affect the brain and spinal cord, however most neurologist find their comfort zone in attending the diagnosis via the brain access.
- This concept resulted in lagging of spinal cord imaging researches compared to brain ones and consecutive underestimation of the opportunity of an important tool sometimes essential to reach a definite diagnosis.
Head injuries top the list of trauma patienrts coming to the casualty. The condition has to be immediately assessed and investigated. Depending upon the findings prompt medical or neurosurgical treatment has to be administered.
paediatric injuries around the elbow
supracondylar elbow injuries
pulled elbow in paediatric age r
radiological signs around elbow in supracondylar fracture humerus
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
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O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
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In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Blunt trauma neck
1.
2. Neck injuries can be very deceiving.
Seemingly minor injuries can quickly become
life threatening.
The insidious nature of injury to this area often
leads to a delay in diagnosis.
Cervical spine fractures are commonly
associated.
Neck must be manipulated carefully until
cervical spine X-rays have been obtained.
Cricoid is most important part of laryngeal
skeleton.
3. Acute injuries to cricoid cartilage pose the
most immediate threat to airway.
Injuries to thyroid present with delayed
airway compromise from expanding
haematoma.
Hyoid injury may even be overlooked
altogether.
The subglottic space in children is very
much more susceptible to internal soft
tissue injury than it is in adult.
4. Given the critical nature of the
contents of the neck, there is a need
for a systematic approach to
evaluation and management.
This approach is based on a good
understanding of the underlying
anatomy.
5. Neck contents are contained by two
discrete fascial layers:
The superficial fascia:
Which envelops the platysma muscle.
The deep cervical fascia:
Contains the sternocleidomastoid and
trapezius muscles.
It is also used to mark the pretracheal
region which includes the trachea,
larynx, thyroid gland.
6. It also invests the prevertebral area
Containing the prevertebral muscles,
phrenic nerve, brachial plexus, and
axillary sheath.
The carotid sheath encloses the carotid
artery, internal jugular vein, and vagus
nerve.
7. Anterior Triangle: Bounded by:
Mandible above
Anterior border of the
sternocleidomastoid muscle posteriorly
Midline of the neck anteriorly
Posterior Triangle:
sternocleidomastoid muscle anteriorly
Trapezius posteriorly
Middle third of the clavicle inferiorly
10. Has fewer vital structural contents:
1. Subclavian artery
2. Brachial plexus
Injury to this area can have catastrophic
outcomes
11.
12. Anatomy classification is excellent for
describing the static location of structures
Injury is not static, and an injury to the
neck may enter the anterior triangle and
then pass through the posterior triangle.
A more useful classification of neck
anatomy for trauma is the Zone
classification developed by Roon and
Christensen
13. This classification system can guide the
clinician in the diagnostic and therapeutic
management
Based on level of injury to the neck in a
caudal to cranial orientation
Zone 1:
Lower Border = Clavicles
Upper Border = Cricoid Cartilage
14. Zone I Structures
Vertebral arteries
Proximal carotid arteries
Major thoracic vessels
Superior Mediastinum
Lungs, trachea
Esophagus
Spinal cord
Cervical nerve roots
16. Begins at the inferior portion of the cricoid
cartilage and extends upwards to the angle
of the mandible
Structures within this area include:
Carotid and vertebral arteries
Jugular veins
Pharynx, larynx, trachea, and esophagus
Cervical spine and spinal cord
18. This zone is located in between the angle of
the mandible and the base of the skull
Vital structures include:
Distal carotid arteries
Vertebral arteries
Pharynx
Spinal cord
21. Neck trauma accounts for 5-10% of all serious
traumatic injuries.
More common in adolescents and young male
adults.
Zone I injuries are associated with the highest
morbidity and mortality rates.
Initially missed cervical injuries secondary to
neck trauma result in a mortality rate of greater
than 15%.
Overall mortality rate is 2-6%.
23. HIGH VELOCITY
INJURIES
Velocity may be so
high that the
wound becomes
compound.
Road traffic
accidents.
Injuries at work.
LOW VELOCITY
INJURIES
Rarely become
compound.
Blows with fists.
Sports injuries.
25. 25
Snowmobile racing.
Motor cycle racing.
Basketball.
Karate.
Sometimes with golf & cricket ball.
Ice hockey.
26. If the driver or front passenger is not belted, he is
in danger of thrusting forward with the head
extended, forcing the anterior neck against the
steering column or dashboard also known as
padded dash syndrome. This leads to crushing of
the trachea usually at the cricoid ring as well as
possible compression of the esophagus against the
vertebrae.
Shoulder harnesses appear to offer some, though
incomplete, protection against blunt neck trauma;
cerebral vessel and laryngeal injuries secondary to
shoulder strap compression have occurred.
27. Form of BNT that occurs typically in young
adolescent patients who ride motorcycles, all-terrain
vehicles, or snow mobiles when they strike a
stationary object such as a wire fence or tree limb.
Clothesline injuries can also occur in high contact
sports.
A large amount of energy is transferred to a small
neck and this leads to crushed laryngeal cartilage
and frequently cricotracheal separation. With
cricotracheal separation, the injured airway is
held together by intervening mucous membranes.
28.
29. Occurs in 10% of all trauma cases.
Victims tend to die at the scene.
Form of BNT that consists of
◦ Homicidal strangulation: ligature suffocation or
manual choking
◦ Suicidal strangulation:
◦ Postural asphyxiation: seen in children; occurs
when the neck is placed over an object and the
body weight produces compression.
30. Significant cervical spine and spinal cord
damage happens in only those hangings that
involve a fall from a distance greater than the
body height.
◦ General strangulation can be associated with
delayed laryngeal edema.
◦ Homicidal strangulation: injures via carotid
artery occlusion or carotid sinus reflex death;
CSRD is a disputed mechanism of death in
which manual stimulation of the carotid sinus is
believed to cause strong glossopharyngeal nerve
impulses leading to terminal cardiac arrest.
31. Suicidal strangulation: Injury associated with
larynotracheal separation and neurovascular
injuries. The mechanism of action for suicidal
strangulation is the following: pressure is
applied to jugular veins leading to obstruction of
venous return from the brain. This results in
venous congestion in the brain and loss of
consciousness ensues. The patient falls with his
or her full weight against the ligature and the
trachea is compressed, restricting airflow to the
lungs. This results in irreversible asphyxiation
or death.
32. Incidence: It is infrequently associated with BNT &
is present 3%-14% of the time with laryngeal
fractures.
MOA: Compression of the cornu of the thyroid
cartilage or other parts of the laryngeal cartilage
against the cervical spine.
Clinical features: Subcutaneous emphysema,
dysphagia, odynophagia, hematemesis, hemoptysis,
tachycardia, fever.
33. Evaluation: Gastrografin study
recommended as first line, if negative,
consider barium swallow (greater sensitivity
of about 90%); endoscopy – rigid &/or
flexible endoscopy.
Management: observe - if clinical exam is
benign; if surgical - then debridement with
two-layered primary closure +/- muscle flap
over suture line to prevent TE fistula.
34. Incidence: reported as highly associated with BNT
but no exact statistics
MOA: Can be caused by severe hyperextension
during acceleration/deceleration motor injuries.
Significant cervical spine and spinal cord damage
can occur in hangings that involve a fall from a
distance greater than the body height. Cervical
spinal disruption subsequent to strangulation is
almost uniformly fatal.
35. Clinical features: Hemiplegia, quadriplegia, CN deficits,
change of sensorium, Horner’s syndrome, neurogenic
shock.
Evaluation: Concern for cervical spine injuries arises
based on clinical exam and imaging – AP and lateral
cervical radiography plain films and CT scan.
Management: NS should be consulted for any surgical
intervention. From the ENT standpoint, cervical
stability is important to establish especially in the event
of tracheostomy placement or endoscopy. Cervical spine
precautions including cervical spine immobilization and
supine placement of the patient on a backboard are
necessary.
36. Incidence: 1-3% of all BNT, 20-30% mortality
Mode of action:
Direct forces can shear the vasculature.
Excessive rotation and/or hyperextension of
the cervical spine causes distention and
stretching of the arteries and veins producing
shearing damage and resultant thrombosis.
Basilar skull fractures may disrupt the
intrapetrous portion of the carotid artery.
37. “Hard signs” – bruit/thrill, expanding or
pulsatile hematoma, pulsatile or severe
hemorrhage, pulse deficit.
“Soft signs” – hypotension, shock, stable
hematoma, CNS/PNS ischemia.
Note: often blunt vascular injury in the form of
acute ischemic stroke is the initial manifestation
of BNT in patients with a delay in presentation of
symptoms.
Classic presentation: A neurologically intact
patient who develops hemiparesis after a high-
speed MVC.
38. Evaluation: Four-vessel angiography remains gold
standard – sensitivity of 99%. CTA 68%
sensitivity, 67% specificity. MRA 75%, 67% for
specificity and sensitivity, resp. Duplex US
sensitivity 90-95% with a skilled technician.
Management: Depending on extent of injury.
Surgical repair preferred over ligation; primary
repair preferred over grafting.
43. 43
Fracture of hyoid bone.
Odynophagia, dysphagia.
Swelling of base of tongue.
Bleeding into soft tissues of
paraglottic space.
44. 44
Fracture the skeleton of larynx.
Fate of thyroid cartilage depends on
its degree of calcification and thus on
age of patient.
45. 45
Minimal injury results in no fracture.
If there is any rigidity or force is great
enough, cartilage will split down front &
down thyroid prominence.
Inherent elasticity allow it to spring back.
Disruption of anterior commissure.
Epiglottis falls backwards.
46. 46
Vocal cords literally roll up on
themselves towards arytenoids.
As thyroid becomes compressed
against cervical spine, arytenoids are
sandwiched.
Bleeding into interarytenoid space &
subsequent swelling.
47. 47
Shatter rather like an egg.
Loss of thyroid prominence.
Arytenoids are sandwiched.
48. 48
Only complete ring in respiratory
tract.
If disrupted then it will stenose.
Very difficult defect to repair.
Soft tissue injury from high velocity
blunt injuries separates the trachea
from cricoid.
64. Group 1:
◦ Minor endolaryngeal hematomas or lacerations, no
detectable fracture
◦ Treatment: humidified O2 and observation
Group 2:
◦ Edema, hematoma, minor mucosal disruption
without exposed cartilage, non-displaced fracture,
varying degrees of airway compromise
◦ Treatment: tracheostomy to secure the airway along
with panendoscopy
65. Group 3:
◦ Massive edema, large mucosal lacerations, exposed
cartilage, displaced fracture(s), vocal cord immobility
◦ Treatment: tracheostomy along with exploration and
repair
Group 4:
◦ Same as group 3 but more severe with severe mucosal
disruption, disruption of the anterior commissure, and
unstable fracture, 2 or more fracture lines
◦ Treatment tracheostomy along with exploration and repair
with stent placement
Group 5:
◦ Complete laryngotracheal separation
◦ Treatment: urgent tracheostomy along with exploration
and repair
66. 66
Admission to the ICU for strict monitoring.
Serial flexible nasolaryngoscopy
examinations.
High humidity atmosphere.
Oxygen may be given.
Antibiotic therapy.
Maximal dose parental steroid therapy.
Antireflux therapy.
67. ◦ Lacerations involving free margin of the
vocal fold
◦ Large mucosal lacerations
◦ Exposed cartilage
◦ Multiple & displaced, or unstable, or
comminuted cartilage fractures
◦ Avulsed or dislocated arytenoids cartilages
68. ◦ Vocal fold immobility or detachment of the
anterior commissure
◦ Cricotracheal separation.
◦ Fractures of the median or paramedian parts
of the thyroid alae.
◦ Cricoid fracture.
◦ Airway compromise.
◦ It is recommended that all surgical patients
receive panendoscopy intraoperatively for a
detailed examination of the injury before
surgical repair.
69. 69
Majority do not require open exploration.
Most will require observation in hospital at
least overnight for laryngeal oedema &
airway obstruction.
If either of these is disturbed, larynx
should be intubated and later explored and
reconstructed.
70. 70
Many of these patients will end up with a
poor voice if glottis has been damaged.
Unusual for these patients to require a
permanent tracheostomy.
71. 71
Half the patients will require laryngeal
exploration and reconstruction.
Skeletal damage is repaired by
reconstitution using stents.
Soft tissue injuries are dealt with by
reducing bleeding, evacuating spaces, &
using quilting sutures.
If cricoid is injured, primary repair should
be attempted.
72. 72
If failed then one of the many
techniques applied to chronic cricoid
stenosis be used.
Seperation of cricotracheal membrane
is dealt with fairly reasonably by
drooping the larynx in neck and
pulling the trachea upwards for an
end-to-end anastomosis, excising any
damaged tracheal rings.
73. 73
If only the glottis is involved then
results with regards to breathing
should be good.
If subglottis is involved the patient
faces certain future surgery for
chronic subglottic stenosis.
74. BNT is not common in children; however,
LT injury is most commonly related to in
BNT in children.
Bicycle accidents and falls are common
causes in younger children
The larynx is situated higher in neck and
protected by mandible
Lies at C3 level in the neonate and
descends during first 3 years of life to
its adult position at C6.
75. Less laryngeal fractures because of
elasticity of cartilages
Submucosal tissues are loosely attached to
the underlying perichondrium, increasing
the likelihood of soft tissue damage like
edema or hematoma and subsequent airway
obstruction.
Controversy in intubation vs tracheostomy.
It is usually not possible to perform an
awake tracheostomy; It is recommended to
manage with intubation followed by prompt
tracheostomy.