The local fire department transported this 25 year-old male to the emergency department shortly after he was accidentally run over by a Bobcat skid steer at work. He reportedly had a transient loss of consciousness and was found lying prone on the concrete floor. In the emergency department, the patient was in severe distress and complained of pain to his back, and pelvic region. In addition he stated that he was unable to see out of his eyes.
What are your concerns as you enter the examination room. What is this
Dx: Traumatic Asphyxia (or Perthe’s Syndrome)
Figure1: demonstrates facial cyanosis
Figure 2: demonstrates the associated ocular injuries of
subconjunctival hemorrhage, chemosis and facial petechia
Traumatic asphyxia or Perthe’s syndrome is an uncommon syndrome associated with facial petechiae, craniofacial cyanosis, and subconjunctival hemorrhage. Usually caused by blunt chest wall injury which is severe and transient in nature, this syndrome may be associated with industrial accidents, ejection from motor vehicles, crush injuries from working under vehicles, or children crushed by household furniture. The injury occurs in adults due to the sudden rise in intrathoracic pressure against a closed glottis or compressed tracheobronchial tree. In children, a closed glottis in addition to the compliant chest wall and absence of valves, allows the acute rise in intrathoracic pressure to be transmitted via the central venous system to a variety of organs systems including the brain, spleen, liver and kidneys. Associated injures include head injury (loss of consciousness or mental confusion), pneumo or hemothorax and pulmonary contusions, cardiac contusions, rib or extremity fractures, and brachial nerve injuries. Although rarely reported in the literature, traumatic retinopathy with associated retinal vein hypertension and reflex vasospasm may be associated with transient blindness. An understanding of the pathophysiology associated with this injury complex is of utmost importance in the management of these patients: the craniofacial abnormalities are usually not life threatening however the associated injuries as aforementioned are potentially lethal.
This patient underwent a complete body scan including CTA of the chest and neck. These studies demonstrated multiple lumbar transverse process fractures, severe pubic symphysis diastasis and bilateral sacroiliac joint disruptions. His craniofacial cyanosis and ocular abnormalities all resolved and he was eventually discharged from the hospital.
References:1: Traumatic Asphyxia Syndrome Tenn Med. 1997 Apr;90(4):144-6.
2: Neuologic Concequences of Traumatic AsphyxiaJ Trauma. 1992 Jan;32(1):28-31
3: Traumatic Asphyxia in Children J Cardiovasc Surg (Torino). 1997 Feb;38(1):93-5
Dr. Effron is an assistant professor at Case Western Reserve University and consultant emergency physician at the Cleveland Clinic Foundation.