Male With Torso Injury
Article Outline
A 49-year-old man sustained a crushing injury to the torso as a lawn tractor rolled over him while he was driving it up the ramp of a flatbed trailer. He was briefly apneic while pinned in a jack knife position. He appeared cyanotic over his face and neck with scattered petecchiae over his upper torso and face (Figure 1, Figure 2). His examination also revealed bilateral subconjunctival hemorrhages (Figure 3). He remained neurologically intact despite an anterior compression fracture of the L2 vertebral body.
Figure 1.
Demarcation of residual facial plethora.
Figure 2.
Shoulder petechiae.
Figure 3.
Subjunctival hemorrhage. Used with permission of Edward T. Dickinson, MD, Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
Diagnosis
Traumatic asphyxia. Traumatic asphyxia, or Perthes syndrome, is characterized by the presence of subconjunctival hemorrhage, cervical/facial petechiae and edema, and cyanosis secondary to severe compressive forces applied to the torso (farm- or work-related crush injuries).1, 2, 3
The pathophysiology of traumatic asphyxia involves distention of the superior vena cava and its tributary veins, with resulting capillary paresis, with or without capillary rupture.1 The predominant involvement of the head, neck, face, and upper thorax has been postulated to be due to the incompetent valves of the innominate and jugular veins.1, 4
Other clinical findings observed in patients with traumatic asphyxia include sore throat, hoarseness, hemoptysis, hemotympanum, dizziness, numbness, and headaches.3 In general, the skin discoloration and subjunctival hemorrhage associated with traumatic asphyxia usually resolve within 1 month.3
It is not unusual for patients with traumatic asphyxia to have associated significant head (67%), thoracic (58% to 79%), or abdominal (50%) injuries.2, 3, 5, 6, 7 Cerebral injury may be present after a prolonged period of asphyxia and is usually secondary to cerebral hypoxia.8
Death is rarely due directly to the traumatic asphyxia itself, and the treatment and outcomes of patients with traumatic asphyxia is usually based on associated injuries.1, 3 In cases of isolated traumatic asphyxia, oxygen supplementation and head elevation to 30 degrees constitute the mainstay of treatment.3
References
- . Traumatic asphyxia: report of four cases. J Bone Joint Surg. 1927;9:106–110
- Perthes syndrome (The classical symptom triad as a rarity in trauma surgery practice). Unfallchirurg. 2001;104:191–194
- . Traumatic asphyxia. Plast Reconstr Surg. 1994;93:739–744
- Difficult airway management in a patient with traumatic asphyxia. Anesth Analg. 1997;85:216–218
- . Neurologic consequences of traumatic asphyxia. J Trauma. 1992;32:28–31
- The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults—a 25-year study. Forensic Sci Int. 2006;159:200–205
- . Long-term followup after traumatic asphyxia. J Trauma. 1985;25:838–841
- . Traumatic asphyxia during stadium stampede. Centr Afr J Med. 2004;50:69–72
For the diagnosis and teaching points, see page 167.
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PII: S0196-0644(08)00798-1
doi:10.1016/j.annemergmed.2008.05.010
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
