SAEM Clinical Images Series: Only a Flesh Wound

2023-09-14T13:12:37-07:00

Sep 29, 2023 | SAEM Clinical Images, Trauma

By: Andrew Shannon, MD, MPH |Editors: Jessica Hoglund, MD; Moises Gallegos, MD, MPH

flesh

A 49-year-old male was triaged to the Fast Track area with complaints of an abrasion to the neck following an assault. The patient was attending a party with his family when “someone started shooting.” The patient believes some stucco or stone fragment from a brick wall struck him in the neck during the initial incident, but his primary concern was for his more seriously wounded family members. He now presents requesting “Neosporin.” His tetanus status is out of date.

Additional Images

Physical Exam

General: Well-appearing male in no distress

Neck: Hemostatic wound to his left neck. No significant pain, no hematoma, no bruits.

Neuro: Exam is non-focal

Laboratory Data

Non-contributory

Case Question: In what anatomical zone of the neck has this injury occurred?

This is a zone 2 injury to the neck. Despite the small size of the wound, a piece of metallic shrapnel from the splintered bullet is noted adjacent to the carotid on CT imaging. Penetrating wounds can be deceptively innocuous, and a high index of suspicion is required. In cases where the nature of the missile is known, plain films or POCUS may be a reasonable first step, but CT imaging would be definitive.

Case Question: In this stable patient without apparent vascular injury on CTA, what neurologic findings might prompt angiography to rule-out violation of the carotid sheath?

Development of hoarseness or a Horner syndrome on the affected side may indicate involvement of the carotid sheath, and an angiogram may be considered, though CTA compares favorably to angiography in penetrating as opposed to blunt arterial trauma.

Case Discussion

Take-Home Points

“Superficial” wounds must be evaluated diligently for any signs of deeper extension, and advanced imaging obtained for any suspicious findings or concerning mechanism of injury.

CTA is likely to be adequate in most cases of penetrating trauma, but a role may still exist for angiography in the presence of compelling clinical findings.

References

Goodwin RB, Beery PR 2nd, Dorbish RJ, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. The Journal of Trauma. 2009 Nov;67(5):1046-1050. DOI: 10.1097/ta.0b013e3181b83b63. PMID: 19901666.
Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000 Aug;216(2):356-62. doi: 10.1148/radiology.216.2.r00jl25356. PMID: 10924553.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.