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Jason Showmaker MD Matthew Page MD

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History Mechanical Properties of Projectiles Anatomic considerations Vascular injury, laryngeal injury*, esophageal injury*, Neuropathy • Diagnosis
• Signs and symptoms • Imaging Techniques

• Management
• Zone Algorithm • “No Zone” Approach

• Cases

• Earliest description >5,000 years ago • Homer’s Iliad – Achilles lances Hector in suprasternal notch • Ambrose Pare (1510-1590)
• First documented treating a patient by ligating the carotid artery and jugular vein of a soldier with a bayonet wound.

• 1800’s more documented cases of ligating lacerated carotids

71(2):267-96.4:951. Velnziano CP. OEF Civilian Experience ? ? ? 4193 15 12 12 3.7-5. and Chipps JE.9 . The controversy surrounding zone II injuries. U S Armed Forces Med J 1954. Surg Clin North Am 1991. Vietnam Gulf Wars OIF. Falcone RE.5 • Civil War – WWI • Observation American Civil 4114 War Spanish188 American War World War I World War II Korea 594 851 ? • WWII • Exploration if platysma penetrated • Korea • Mobile Army Surgical Hospitals (MASH) Data from Asensio JA. Management of penetrating neck injuries. Makel HP.Wartime Advancements War # Cases Mortality % 15 18 11 7 2. et al. Canham RG. Intermediate treatment of maxillofacial injuries.

and Chipps JE. Canham RG. Intermediate treatment of maxillofacial injuries. Management of penetrating neck injuries. Vietnam Gulf Wars OIF. Velnziano CP.71(2):267-96. The controversy surrounding zone II injuries. OEF Civilian Experience ? ? ? 4193 15 12 12 3. Surg Clin North Am 1991.7-5. U S Armed Forces Med J 1954.Wartime Advancements War # Cases Mortality % 15 18 11 7 2. Falcone RE. Makel HP. et al.9 .4:951.5 • Civil War – WWI • Observation American Civil 4114 War Spanish188 American War World War I World War II Korea 594 851 ? • WWII • Exploration if platysma penetrated • Korea • Mobile Army Surgical Hospitals (MASH) Data from Asensio JA.

71(2):267-96. U S Armed Forces Med J 1954. Velnziano CP. Makel HP. OEF Civilian Experience ? ? ? 4193 15 12 12 3. Canham RG. Surg Clin North Am 1991.Wartime Advancements War # Cases Mortality % 15 18 11 7 2. The controversy surrounding zone II injuries. Falcone RE. et al. and Chipps JE. Vietnam Gulf Wars OIF.5 • Civil War – WWI • Observation American Civil 4114 War Spanish188 American War World War I World War II Korea 594 851 ? • WWII • Exploration if platysma penetrated • Korea • Mobile Army Surgical Hospitals (MASH) Data from Asensio JA. Intermediate treatment of maxillofacial injuries.4:951.7-5. Management of penetrating neck injuries.9 .

The controversy surrounding zone II injuries. Surg Clin North Am 1991. Intermediate treatment of maxillofacial injuries.Wartime Advancements • Vietnam • High velocity rifles War # Cases Mortality % 15 18 11 7 2. and Chipps JE.7-5. knives. etc Korea Vietnam Gulf Wars OIF. U S Armed Forces Med J 1954. et al. Makel HP. Croatia. Canham RG. Civilian Experience .5 • Gulf Wars. OEF ? ? ? 4193 15 12 12 3. OIF American Civil 4114 War Spanish188 American War 594 851 ? • Improvised Explosive Devices World War I World War II • Body Armor • Civilian Experience • Handguns. Falcone RE.71(2):267-96. Velnziano CP. Balkans.4:951.9 Data from Asensio JA. Management of penetrating neck injuries.

• Penetrating Neck Injury is present in 5-10% of all trauma cases. (Hom DB) • Multiple vital structures present • Vascular system • Air passages • Upper Gastrointestinal passages • Neurologic system .

brachial plexus. sympathetic chain . subclavian. peripheral nerves. Jugular. aortic arch • Air passages • Pharynx. cranial nerves. lungs • Upper Gastrointestinal passages • Pharynx. trachea.• Penetrating Neck Injury is present in 5-10% of all trauma cases • Multiple vital structures present • Vascular system • Carotid. innominate. Larynx. esophagus • Neurologic system • Spinal cord.

• Stab injuries – Knife. etc • Predictable damage pathway • Stab vs. Projectile Injury • Higher incidence of subclavian laceration • Lower incidence of spinal cord injury • Projectile • Handgun • Rifle • Shotgun . razor blades. glass.

.• Kinetic Energy of Projectile • KE = ½ Mass(Ventry-Vexit)2 • Handguns – Lower muzzle velocity (210-600 m/s) • Shotguns – Low muzzle velocity (300 m/s) • Rifles – High muzzle velocity (760 – 2.000 m/s) • Muzzle velocity >610m/s • Create a temporary cavity up to 30 times the missile size.

youtu be.• http://www.com/watch?v= 9uEXeXXbDYg .

see above • Yaw – “tumbling” • More tumble = more transmitted energy.• Kinetic Injury of Missile: more energy = more damage • Velocity: higher velocity = more KE. larger damage path • Casing – alters flight dynamics and penetration dynamics • Strong metal jacket allows through and through injury • Lead casings leave a trail on Xray .

pathway through tissue .• Bullet Tip • “Expanding bullet” – hollowpoint. softnose • More energy transmission and more soft tissue injury • Entry/Exit wound.

Cummings Ch. 115 .

115 . Bagheri. SC 2008 Cummings Ch.• Three anatomic zones described as a method of classifying injury.

Lung apices • Esophagus • Thoracic duct Bagheri.• Boundaries: • Clavicles and sternal notch up to cricoid cartilage • Vasculature • • • • Arch of Aorta. Innominate vessels Subclavian vessels Proximal Carotid Arteries Vertebral Arteries • Aerodigestive • Trachea. spinal cord . SC 2008 • Neurologic • Brachial plexus.

SC 2008 • Mortality – 12% .• Dangerous Area • Close proximity of vasculature to thorax • Osseous Shield • Protects against injury • Surgical Access difficult • Surgical Access • May require sternotomy or thoracotomy • Mandatory exploration is NOT recommended Bagheri.

SC 2008 .Bagheri.

Internal and External • Jugular veins • Aerodigestive • Larynx. sympathetic chain Bagheri.• Boundaries: • Cricoid cartilage to angle of mandible • Vasculature • Common Carotid. Hypopharynx. SC 2008 . spinal cord. Proximal Esohpagus • Neurologic • Cranial Nerves.

• Largest and most commonly involved area ~60-75% • No Osseous Shield • Surgical Access “Easy” • Proximal and Distal control of vasculature “easy” • Fascial layers may tamponade • Elective vs Mandatory Exploration Bagheri. SC 2008 .

115 . SC 2008 Cummings Ch.Bagheri.

• Boundaries: • Angle of mandible to base of skull • Vasculature • • • • • Internal Carotid External Carotid Vertebral Artery Prevertebral venous plexus Jugular veins • Aerodigestive • Oral cavity. spinal cord Bagheri. Pharynx • Neurologic • Cranial nerves (trunk of VII). SC 2008 .

SC 2008 .• Dangerous Area • Proximity of vasculature to skull base • Osseous Shield • Protects against injury • Surgical Access difficult • Surgical Access • Mandibulotomy • Craniotomy • Mandatory exploration is NOT recommended Bagheri.

• Pearls • Cranial neuropathies may be indicative of injury to nearby vasculature • Frequent examination oral cavity .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• Indications for Mandatory Immediate Surgical Exploration Shiroff AM 2013 .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• • • • • • • Respiratory distress Stridor Hoarseness Hemoptysis Tracheal Deviation Subcutaneous Emphysema Sucking Wound Fikker BG 2004 .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• • • • • • • • Hematoma Persistent Bleeding Absent Carotid Pulse Bruit Thrill Hypovolemic Shock Change of Sensorium Neurologic Deficit Munera F 2000 .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• • • • • • • Hemiplegia Quadriplegia Coma Cranial Nerve Deficit Change of Sensorium Hoarseness *Signs of stroke/cerebral ischemia .

• • • • • • ABC’s Hard Signs Airway signs Vascular signs Neurologic signs Esophageal signs .

• • • • • • • Subcutaneous Emphysema Dysphagia Odynophagia Hematemesis Hemoptysis Tachycardia Fever Rathlev NK 2007 • Most commonly missed zone II injury • Significant Delayed morbidity and mortality .

laryngeal injury*. Neuropathy • Diagnosis • Signs and symptoms • Imaging Techniques • Management • Zone Algorithm • “No Zone” Approach • Cases .• • • • History Mechanical Properties of Projectiles Anatomic considerations Vascular injury. esophageal injury*.

rigid bronchoscopy. rigid esophagoscopy • Flexible endoscopy • Gastrograffin/Barium swallow .• • • • Angiography Carotid Ultrasound CT Angiography MRI/MRA • Direct laryngoscopy.

angle of mandible • Hard signs present any zone  OR • Injury to Zones I or III – Angiography and endoscopy • Injury to Zone II – mandatory exploration if platysma penetrated .• In 1979 Roon and Christensen classified injuries by site of penetration using external landmarks – sternal notch. cricoid.

Shiroff AM 2013 .

• Scrutiny of mandatory Zone II exploration • Negative exploration rates range from 50-70% • Missed injuries • Increased hospital stay • 1993 – Atteberry described 53 patients with zone II injury managed selectively • 19 pts immediate exploration based on physical exam findings • 34 pts observed: angiography/endoscopy performed • No missed vascular injuries .

• Injury to Zones I or III – Angiography and endoscopy • Injury to Zone II – mandatory exploration if platysma penetrated Shiroff AM 2013 .

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• Numerous studies comparing. no clear winner Obeid F 1985 .

Obeid F 1985 .

• Scrutiny of Traditional Zones Approach • “Maximally Invasive” – risks/cost/operator error/operator availability of angiography and endoscopy • Developed prior to the development of modern imaging techniques • No Zone Approach • Unstable patients treated the same as Traditional Approach • Zone description eliminated. injury to any of three zones in stable patient is evaluated with CT/CTA .

Shiroff AM 2013 .

• No Zone Approach
• Unstable patients treated the same as Traditional Approach • Injury to any of three zones in stable patient is evaluated with CT/CTA

Shiroff AM 2013

• Described by Gracias et al Arch Surg 2001
• Demonstrated at 50% decrease in the use of angiography and 90% decrease in the use of endoscopy

• Identification of missile trajectory guides subsequent diagnostic and therapeutic interventions.
• If remote from vital structures the no further workup

Munera F 2004

quick • Limited interuser variability • Safe • Shows surrounding structures Limitations Poor timing of contrast load Patient movement Metallic artifact Body habitus Not therapeutic .• Advantages • Superior image quality • Readily available.

Some cases .• Mechanism of injury is emphasized • Thorough physical examination is key • Hard signs indicate need for immediate surgical exploration of any zone • Stable patients with Zone I and III injury undergo angiography and endoscopy • Stable patients with Zone II injury undergo surgical exploration or angio/endoscopy • Evaluating with CT Angiography may allow for less utilization of services and is effective and reliable. • ….

• Bleed profusely initially but seems to have slowed • Arrives in ED . stabs him.• 27 yo male baking cookies with his grandma when a stranger walks in the house. and runs away.

angiography allowed for stenting over flap to re-establish flow.• Subclavian intimal flap seen on CTA. .

• 22 yo male walking his son home from church in Prague when a stranger shoots him with a handgun and runs away. EMT arrived to scene and pt bleeding profusely and unconcious. • Intubated and transferred to trauma center. .

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2011 .O’Brien PJ.

he’s never shot a gun before.• 45 yo male takes his friend to a firing range. throws some band-aids on and drives to the ED. 2011 . • Friend accidentally shoots him in the neck above cricoid with a 9mm. Zaidi SMH.

Munera F 2004 .

• 28 yo male hunting on public land that is densely populated with hunters. . He is inadvertently shot with a 12 gauge slug from 30 meters away.

Munera F 2004 .

• 18 yo male in a bar stabbed from behind mandibular angle coursing anteriorly • Examination vitals stable • Oral cavity – no parapharyngeal or retropharyngeal hematoma • Asymmetric palatal rise. and ipsilateral shoulder is weak. What vessel is at risk for injury? . voice is hoarse.

Reilly PM. PhilpottJ. Multidetector row computed tomography in the management of penetrating neck injuries. Evaluation and Treatment of Penetrating Cervical Injuries.136:1231-5. Cox MW. Penetrating neck trauma: a case for conservative approach. Maisel RH. Arch Surg 2001. Bagheri. 1979. Christensen N. Ch. Gracias VH. Shiroff AM. Am J Otolaryng. Zaidi SMH. Am Surg 2013. Danton G. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. 2011. Roon AJ. et al. • Munera F. Cummings Otolaryngology Head and Neck Surgery. Penetrating neck trauma: a review of management strategies and discussion of the ‘no zone’ approach. et al.30:195-204. 115. Rivas LA.19:391-7. Semin Ultrasound CT MRI 2004. 20:393-414. . A modern approach to cervical vascular trauma. Khan HA. O’Brien PJ. Perspect Vasc Surg Endovasc Ther 2011 23: 90.32:591-6.• • • • • • • Hom DB. Ahmad R. Gale SC. Bell RB. J Trauma. Niels MD. Penetrating neck injuries. • Images as cited or hyperlinked in powerpoint. Penetrating and blunt trauma to the neck. Oral Maxillofacial Surg Clin N Am 2008.79:23-29. SC.