DR PRIYANKA

 Complex network of neurovasuclar & muscular

structures supported by various fascial planes.
 In the neck multiple vital structures are vulnerable to
injury in a small anatomic area and not protected by
bone.
Neck Injuries
Neck trauma mechanisms:
blunt
penetrating : 5-10% of all trauma cases

The types of injuries:

airway (laryngotracheal),
digestive tract (pharyngoesophageal),
vascular system
neurologic system
PENETRATING INJURIES
Stab injuries –Knife, razor blades, glass, etc
•Predictable damage pathway
•Stab vs. Projectile Injury
•Higher incidence of subclavian laceration
•Lower incidence of spinal cord injury
•Projectile
•Handgun
•Rifle
•Shotgun
 Three basic types: low velocity
(handguns), high velocity
(rifles) and shotguns.
 Handguns ~ 400ft/lb,
 Rifles 3000ft/lb,
 Shotgun energy and impact
varies with distance
Projectile injury mechanics
Kinetic Injury of Missile: more energy = more damage
•Velocity: higher velocity = more KE,
•Yaw –“tumbling”, deflection of the bullet around the
axis of the travel.
•More tumble = more transmitted energy, larger
damage path
•Strong metal jacket allows through and through
injury
HANDGUNS-
 Classified by projectile type, speed and calibre.
 Tumbling bullet : deflection of the bullet around the
axis of the travel, causes more injury in a wider path
 Low velocity bullets(lead shielded) leave a radiographic
pathway
RIFLE
 Hunting rifle- soft tip bullets create larger cavity, no exit
wound, fragments causing injury far away from
primary path.
 Military rifle- bullets create clean hole, through and
through wound without lead track to follow
 High velocity missiles tears tissues & transmits energy
to surrounding tissue.
 Cavity upto 30 times size of missile created & pulsate 5-
10ms creating
 waves of contraction and expansion of tissues.
 Hence the finding of punctured viscus without direct
penetration- alerts the surgeon to examine trachea and
esophagus even when bullet is 2 inches away.
 Bullet Tip
 •“Expanding bullet” –hollowpoint, softnose
 •More energy transmission and more soft tissue injury
 •Entry/Exit wound, pathway through tissue
ZONES IN NECK
 Roon & Christensen`s Classification
Zone 1: superiorly from the sternal notch & clavicles
to the cricoid cartilage (injury affects both neck &
mediastinal structures)
Zone 2: cricoid cartilage to the angle of the
mandible
Zone 3: angle of the mandible to the
ZONES OF NECK - CONTENTS
 Zone I: includes the
vertebral and proximal
carotid arteries, major
thoracic vessels, superior
mediastinum, lungs,
esophagus, trachea,
thoracic duct, spinal cord
 Zone II: involve the carotid and vertebral arteries,
jugular veins, esophagus, trachea, larynx, and spinal
cord
 Zone III: includes the distal carotid and vertebral
arteries, pharynx, and spinal cord
 ZONE I considerations
 Dangerous Area, Mortality –12%
 •Close proximity of vasculature to thorax
 •Osseous Shield : bony thorax and clavicle
 •Protects against injury
 •Surgical Access difficult
 •Surgical Access
 •May require sternotomy or thoracotomy
 •Mandatory exploration is NOT recommended
 ZONE II considerations
 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
 ZONE III considerations
 Dangerous Area
 •Proximity of vasculature to skull base, high carotid
injury
 Cranial nerve injury at skull base
 •Surgical Access difficult
 •Surgical Access
 •Mandibulotomy
 •Craniotomy
 •Mandatory exploration is NOT recommended
 •Cranial neuropathies may be indicative of injury to
nearby vasculature
 •Frequent examination oral cavity
FASCIAL PLANES
 Platysma: thin muscle covers the entire anterior triangle
and the anteroinferior aspect of the posterior triangle;
serves as an important planar landmark when evaluating
penetrating neck injuries

 Deep cervical fascia: invest deep structures; important due

to the pretracheal deep fascia’s communication to the
anterior mediastinum (neck trauma can lead to
mediastinitis)
SIGNS AND SYMPTOMS
 AIRWAY :

.Respiratory distress
•Stridor
•Hoarseness
•Hemoptysis
•Tracheal Deviation
•Subcutaneous Emphysema
•Sucking Wound
 VASCULAR:

•Hematoma
•Persistent Bleeding
•Absent Carotid Pulse
•Bruit
•Thrill
•Hypovolemic Shock
•Change of Sensorium
•Neurologic Deficit
 NEUROLOGIC
•Hemiplegia
•Quadriplegia
•Coma
•Cranial Nerve Deficit
•Change of Sensorium
•Hoarseness
•*Signs of stroke/cerebral ischemia
 ESOPHAGEAL INJURIES
•Subcutaneous Emphysema
•Dysphagia
•Odynophagia
•Hematemesis
•Hemoptysis
•Tachycardia
•Fever
•Most commonly missed zone II injury
•SignificantDelayedmorbidity and mortality
Hard Signs
 Ongoing hemorrhage
 Large or expanding hematoma
 Bruit
 Massive blood loss at scene
 Hemiparesis or hemiplegia
 Extensive subcutaneous emphysema
 Stridor
INITIAL MANAGEMENT
 ABC’s
 Always be ready for Intubation,
Cricothyroidotomy, Tracheostomy (multible
intubation attempts might enlarge a pyriform
sinus laceration/ tracheal tear may be exacerated
by neck extensions)
 Extension of neck should be avoided until a
cervical spine injury is ruled out
 Direct pressure for bleeding
 AP and Lateral neck and chest x-rays( chest tube
insertion in pneumothorax)
 Look for vascular injury(pulse deficit,active
bleeding,hypotension, expanding hematoma) in
high volume trauma
 Acute spinal injury- hypotension without
tachycardia
 Look for Cranial Nerve injury, in cases with 12th
nerve injury suspect carotid artery injury
 Horners Syndrome- injury to sympathetic chain or
carotid atery
DIAGNOSTIC EVALUATION
.Angiography
•Carotid Ultrasound
•CT Angiography
•MRI/MRA
•Direct laryngoscopy, rigid bronchoscopy, rigid
esophagoscopy
•Flexible endoscopy
•Gastrograffin/Barium swallow
CT ANGIOGRAPHY
 Limitations
 Advantages  Poor timing of contrast
 •Superior image quality load
 •Readily available, quick  Patient movement
 •Limited  Metallic artifact
interuservariability • Not therapeutic
 •Safe
 •Shows surrounding
structures
 Angiography
 In zone I and zone III : routinely
 When b/l neck involved, 4 vessel angiography : b/l
carotid and vertebral arteries
 Zone II injuries : easily accesible, low risk for
exploration
 Angiography : stable pts with persistent hemorrhage /
neurologic deficits
MANAGEMENT

 Zone 1 dangerous area- vascular strusture close to

neck, osseous shield makes surgical exploration
difficult.
Right side approached through median
sternotomy, left side by left anterior thoracotomy.
High fatality rate.
 Zone 2 –common 60-75%
Mandatory or selective exploration depending on
signs, symptoms, haemodynamic stability,
diagnostic radiographic , endoscopic techniques,
angiography

 Zone 3- protected by skeletal structures and

difficult to explore. May need to displace or divide
mandible.
Injury to cranial nerves exiting skull base indicate
injuries To great vessels in their proximity(may
necessitate craniotomy for exploration)
MANDATORY VS SELECTIVE MANAGEMENT
 Mandatory immediate surgical exploration
Massive bleeding, expanding hematoma, non
expanding hematoma with haemodynamic
instability, haemomediastinum, hemothorax,
hypovolemic shock

 Selective exploration
Hemodynamically stable, non life threatening
injuries, Can undergo imaging investigations.
SELECTIVE VS MANADATORY NECK
EXPLORATION
Exploration of Neck
general principles
 GA
 Airway- nasotracheal/orotracheal intubation;
cricothyroidotomy/traecheotomy
 Position- supine, neck extended, turned to opposite
side(if no C spine injury)
 Exposure-chest & face for zone 1 & 3 injuries
 Approach- localised injury :horizontal skin crease
insicion, subplatysmal flaps;
wider exploration: lond incision along anterior border
of sternocleidomastoid.
 Additional exposure:zone 1 divide omohyoid muscle,
for bilateral exploration :apron flap; zone 3 –anterior
dislocation of mandible.
 Active bleeding should be controlled with digital
pressure until direct vascular control is achieved

 Wounds should not be probed, cannulated or locally

explored
 these can dislodge clot and lead to uncontrolled
hemorrhage or embolism
 Operative Approach
• Zone I - SCM incision + sternotomy

• Zone II - SCM incision

• Zone III - post-auricular extension with SCM

incision + mandibular subluxation
 SCM Incision

• Provides exposure of the carotid sheath,

pharynx and cervical esophagus

• Can be lengthened to provide more extensive

proximal or distal exposure

• If bilateral exploration is necessary, separate

incisions can be done
 Cervical Vascular Injuries

• Neck trauma damages cervical vessels in 25%

of cases
• Penetrating trauma predominates
− 30% have associated injuries in the neck and
thorax
• Blunt trauma accounts for < 10% of injuries
− mortality rate = 10 – 30%
 VASCULAR PENETRATION
 Zone I : Thoracic surgery
 low cervical incision : sufficient exposure
 Zone II : Injuries at skull base may require
mandibulotomy for exposure
 ICA injury : fogarty catheter through PruitT Inahara
shunt
 All veins can be safely ligated, if both ijv ‘s injured : one
side repaired.
 Common carotid/ ICA in zone II : exploration is
mandatory
 If the artery is not pulsating : external carotid branches
may be followed retrograde from facial artery at
submandibular/ superiro thyroid artery
 Vascular injuries : end to end anastomosis
autovenous grafting
ligation for irreparable injuries
 Management

• Injuries to the ICA are more problematic

• Simple injuries with no interruption of flow

should be repaired

• Injuries to CCA or ICA with interrupted flow

in the vessel, repair creates a theoretical
disadvantage
 Disadvantage

• Interruption of flow may lead to focal brain

ischemia and partial disruption of blood-
brain barrier
• Sudden restoration of blood flow may cause
hemorrhage in the area of ischemia and
worsen the extent of brain injury
• Converted an ischemic infarct into a
hemorrhagic infarct