Penetrating Neck Trauma

DRADJAT R SUARDI Definitive Surgical Trauma Care.

Introduction
• 5-10% of all trauma • Overall mortality rate as high as 11% • Major vessel injury fatal in 65%, including prehospital deaths • Attending physician must have excellent knowledge of anatomy

Penetrating Neck Trauma

Historical Perspective/ pre WW I • Ligation of the major vessels described as early as 1522 by Ambrose Pare • Ligation was the procedure of choice for vascular injury through WW 1 • Associated mortality rates up to 60% • Significant neurologic impairment in 30 % .

35% for delayed exploration • 40% to 60% rate of negative explorations with mandatory exploration • Present mortality for civilian wounds is 4% to 6% . mandatory exploration with mortality of 65 vs. through the platysma • Fogelman and Stewart reported Parkland Memorial Hospital experience of early..Historical / post WW II • Mandatory exploration of all penetrating neck wounds.

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great vessels of the neck.Anatomy/Zone I • Bound superiorly by the cricoid and inferiorly by the sternum and clavicles • Contains the subclavian arteries and veins. recurrent nerve. the dome of the pleura. esophagus. trachea • Signs of significant injury may be hidden from inspection in the mediastinum or chest .

and hypoglossal nerves • Injuries here are seldom occult • Common site of carotid injury . base of tongue. carotid artery and jugular vein.Anatomy/Zone II • Bound inferiorly by the cricoid and superiorly by the angle of the mandible • Contains the larynx. vagus. pharynx. phrenic.

Anatomy/Zone III • Lies above the angle of the mandible • Contains the internal and external carotid arteries. and several cranial nerves • Vascular and cranial nerve injuries common . the vertebral artery.

3) Subclavian artery (Zone 1) Aortic Arch (Zone I) Lung Apices (Zone I) Esophagus (Zone I & 2) Trachea (Zone I & 2) Thyroid (Zone I) Thoracic Duct (Zone I) Larynx (Zone 2) Pharynx (Zone 2) Jugular vein (Zone 2 & 3) Vagus nerve (Zone 2) Recurrent laryngeal nerve (Zone 2) Salivary and parotid glands (Zone 3) Cranial nerves IX-XII (Zone 3) .2.2.Penetrating Neck Trauma What’s at risk? • Lots of structures! – – – – – – – – – – – – – – – – – Carotid artery (Zone 1.3) Vertebral artery (Zone 1.2.3) Spinal Cord (Zone I.

internal jugular vein. thyroid gland. trachea. vagus nerve .Fascial Layers • Superficial cervical fascia . pericardium – Prevertebral: prevertebral muscles. trapezius muscle – Pretracheal: larynx. phrenic nerve. brachial plexus.platysma • Deep cervical fascia – Investing: sternocleidomastoid muscle. axillary sheath – Carotid sheath: carotid artery.

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Penetrating Neck Trauma Clinical Exam • Platysma muscle – Important landmark – Lies between superficial and deep cervical fascia – Covers the anterolateral neck – IF platysma violated. assume injury to all other deeper structures • Clinical Features – Physical exam unreliable – Signs and symptoms nonspecific .

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and the kinetic energy of any exiting fragments or projectiles • The velocity of the projectile is the most significant aspect of energy transfer (K. remainder from motor vehicle. = 1/2 mv^2 . household. and industrial accidents • The amount of energy transferred to tissue is difference between the kinetic energy of the projectile when it enters the tissue.E.Ballistics • Over 95% of penetrating neck wounds are from guns and knives.

• Muzzle velocity less than 1000 ft/s is considered low velocity • .22 and .357 magnum and .45 as high as 1500 ft/sec • High power rifles: 220-3000 ft/sec • Shotguns at less than 20 feet -..1200-1500 ft/sec .Ballistic cont..38 caliber handguns have a velocity of 800 ft/sec • .

45 caliber handguns can cause extensive damage extending beyond the path of the projectile and should be explored • Stab wounds do not have this effect • Beware of the stab wound just over the clavicle -. • Injuries inflicted with high power rifles. and .the subclavian vein is at high risk .Ballistic cont. shotguns at less than 20 feet.357 and .

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Stabilization/Airway • Established Airway – be prepared to obtain an airway emergently – intubation or cricothyrotomy – beware of cutting the neck in the region of the hematoma -.disruption there of may lead to massive bleeding – must assume cervical spine injury until proven otherwise .

Breathing • Zone I injuries with concomitant thoracic injuries – pneumothorax – hemopneumothorax – tension pneumothorax .

Circulation • Bleeding should be controlled by pressure • Do not clamp blindly or probe the wound depths • The absence of visible hemorrhage does not rule out • Two large bore IVs • Careful of IV in arm unilateral to subclavian injury .

abdominal.stab wounds. high-energy. gunshot wound. extremity injuries • Neurologic history . patient • Mechanisms of injury . trajectory of stab • Estimate of blood loss at scene • Any associated thoracic.History • Obtain from EMS witnesses. low-energy.

cranial nerves. and extremities • Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here • Don’t blindly explore wound or clamp vessel . abdomen. and spinal column • Examine the chest.Physical Examination • Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits • Neuro exam: mental status.

Penetrating Neck Trauma Workup • Controversy regarding management of “soft” or no signs of injury • Soft Signs – – – – – – – – Hemoptysis/hematemesis Oropharygeal blood Dyspnea Dysphonia/dysphagia SubQ or mediastinal air Chest tube air leak Nonexpanding hematoma Focal neuro deficits • Issue of Mandatory versus Selective Exploration? .

Penetrating Neck Trauma CCH neck protocol • Zone I – Angio of arch and great vessels – CXR – Consider esophagus and trachea • Zone II – Angio carotid(s)/vertebral(s) – Esophagram & endoscopy – Consider bronchoscopy • Zone III – Carotid angio – Oropharyngeal exam .

contrast studies as indicated .Radiographs • CXR . look for pneumothorax • Cervical spine film to rule out fractures • Soft tissue neck films AP and Lateral • Arteriograms.inspiratory/expiratory films to assess for phrenic nerve injury.

betadine paint only • Prep vein donor site.Preoperative Preparation • Surgeon and staff ready for emergent/urgent tracheotomy • Gentle cleansing of wound. and chest for possible thoracotomy • Avoid NG tube until airway secure and patient anesthetized .

Penetrating neck trauma Diagnosis Vascular injury Signs and symptoms Shock Hematoma Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck Subcutaneous emphysema Airway obstruction Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia Subcutaneous emphysema Hematemesis Dysphagia or odynophagia Laryngotracheal injury Pharynx/esophagus injury .

maybe • No increase in mortality when adjunctive diagnostic studies and serial exams performed .Exploration vs. Observation • Many experts have adopted a policy of selective exploration • Decreased number of negative explorations. increased number of positive explorations • Decreased cost of medical care.

Penetrating Neck Trauma Management • Unstable patients – Practical Issues • AIRWAY first priority! – Can use orotracheal intubation with RSI in most patients safely – exceptions • Control bleeding with direct pressure – Never blindly clamp vessels in neck • Place IV’s on non-injured side • ED thoracotomy and aspiration of right ventricle for venous air embolism if – Sudden cardiopulmonary arrest – Profound hypotension unresponsive to fluids .

– My backups are essentially a surgical airway! • First line: cricothyrotomy – Advantage: » Fast » Low rate complications – Contraindications: » Anterior neck hematoma » Suspected laryngeal injury • ED tracheostomy – Disadvantages » Technically difficult » Time consuming .Penetrating Neck Trauma Further Airway Management – First line: orotracheal intubation with RSI • Relative contraindications: – Massive facial trauma – Distorted anatomy – Suspected laryngeal injury – What happens if that fails or can’t use it? – Nasotracheal intubation. fiberoptic laryngoscopy and other difficult airway devices are unlikely to be helpful.

Penetrating Trauma Neck
Esophageal Injury
• • Epidemiology
– Represent 0.1% trauma admissions – But mortality rate is high – 22%

Pathophysiology
– Most frequent missed injury in neck!! – Can be a devastating miss
• spillage of orogastric contents leads to mediastinitis and death

Clinical Features
– Difficult diagnosis because no pathognomonic signs and physical exam unreliable – Suggestive signs: hematemesis, odynopahgia, subQ air

Workup
– Various tests suggested – Only one protocol has 100% sensitivity
• Combination of endoscopy followed by contrast swallow study

Management
– Broad spectrum antibiotic coverage – Urgent surgical exploration

Penetrating Trauma Neck
Tracheal Injury
• • Epidemiology
– – – – Account for <1% of all traumas

Clinical Features
Pathognomonic: bubbling from wound Other signs: dysphonia, dyspnea, stridor, hemoptysis, subQ emphysema, bony crepitus Beware cricoid cartilage fracture
• High risk for acute airway obstruction and death

Workup
– – – – Direct laryngoscopy Flex nasopharyngoscopy Bronchoscopy Spiral CT neck (newer modality, unevaluated)

Management
– – – – Clinical judgment needed regarding need for securing airway Airway compromise can be immediate or DELAYED Better to secure airway earlier rather than later (when deal with distorted anatomy) If suspect tracheal injury
• • Traditionally orotracheal intubation contraindicated (convert partial to total LT separation) May attempt cricothyrotomy, otherwise patient needs an ED trach!

clavicle resection. or thoracotomy • High morbidity of exploration.Site/Zone I • Adequate exposure for exploration and repair may require sternotomy. thus suspicion must be great before taking the patient to OR • Cardiothoracic surgery consultation a must • Angiography is essential .

except barium swallow and esophagoscopy where indicated.Site/Zone II • Few injuries will escape clinical examination • Most carotid injuries occur here • Adjunctive studies. are not necessary • Symptomatic zone II injuries can generally be safely managed by observation .

Site/Zone III • High rate of vascular injury. often multiple • Often difficult to obtain proximal and distal vessel control • Exploration has high rate of injury to cranial nerves • Adequate exposure may require mandibular subluxation or mandibulotomy • Angiography needed to delineate site of injury • Embolization techniques of greatest value here .

such as in a rural setting .Clinical Setting • Observation requires admission to an intensive care unit where serial examination can be performed by a surgeon • Adjunctive studies must be available at all times and at a moments notice • Absence of these dictates exploration of all patients .

Pharyngo Esophageal • Gastrografin swallow followed by Barium if negative • Flexible ± rigid esophagoscopy • Invert the mucosal edges and close with two layers of absorable sutures • JP drain and muscle flap .

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or local mucosal flap • A keel or soft stent is placed when denuded areas are opposed • Tracheotomy one ring below injury when high tracheal injury • Suprahyoid muscle release for primary closure of segmental defect . buccal.Airway • DL where laryngeal injury is suspected • Mucosal tears are closed with absorbable sutures • Cover raw surfaces with nasal.

Vascular • The subclavian and internal jugular veins can be ligated without adverse effect • Major arteries should be repaired where possible except the vertebral which can be ligated • Partial lacerations can be closed primarily -.vein patches will help prevent subsequent stenosis • High velocity wounds produce a surrounding area of contusion which may be thrombogenic and which must be resected. then primary reanastamosis if possible .

Vascular cont. vein grafts from the sphenous or internal jugular are interposed • In central neurologic deficits: – repair the artery when there are minimal deficits. with gross deficits restoration of flow can convert ischemic infarcts into hemorrhagic ones -.the artery should be ligated – a deterioration in neurologic status dictates arteriography and reexploration – EC-IC bypass when irreparable injury to ICA . • When tension is required.

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X. contralateral sensory deficit – Brachial plexus – Peripheral nerve roots – Cranial nerves VII.XI.XII .IX.Penetrating Trauma Neck Neurologic Injury • Several neurologic structures vulnerable in neck – Spinal cord • Complete cord injury • Incomplete injury – Brown-Sequard syndrome » Ipsilateral hemiplegia.

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missed esophageal injury causes late mortality .Conclusions • Maintain a healthy respect for apparently minor neck wounds because of potential fatal outcome for initially benign appearing injuries • Do not try to infer trajectories of gunshot wounds from clinical or radiographic studies • Careful history and complete physical exam with appropriate ancillary studies will avoid missed injuries • Arteriography for zone I and zone III injuries • Vascular injuries most immediately lifethreatening.

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BLUNT NECK INJURY Dradjat R Suardi .

Introduction      Infrequent except C-spine Awareness is essential Can be devastating even fatal Signs often subtle or absent Often too late .

Types of Injury  Direct impact Injury due to excessive extension . flexion or rotation Compression   .

Initial evaluation       Airway Conscious patient : voice . stridor ETT is the route of choice Tracheostomy when necessary Be aware of obscured anatomic landmarks Best expertise available .

Initial evaluation Breathing Zona 1 Pneumothorax Pneumomediastinum     .

bloodflow to the brain)  .Initial evaluation Circulation  Two large bore IV cath  Careful monitoring of peripheral pulses  Direct pressure if bleeding occur  Expanding hematoma dangerous ( block airway.

jugular venous distension Laryngotracheal or aerodigestive injury (hoarseness.stridor. contusions .dysphagia) Be aware of subtle signs such as simple discolorations or minimal abrasions .Physical examinations     Inspection : Evaluate the neck for lacerations .

Physical examinations Auscultations : Bruit over Carotid Artery Palpations : Pulse deficit or thrills Step off sign Anatomical structure loss Subcutaneous emphysema .

CXR Cervical immobilizations should continue untill clinically and radiographycally cleared Pretracheal soft tissue > 0.Radiographic evaluations     Lateral C spine X ray . retropharingeal air .5 mm is suggestive C-spine fracture Subcutaneous empysema .

Diagnostic modalities    CT scan Strengths : excellent for identifying injuries to the larynx and vert. requires IV contratst .column Weakness : Not sensitive enough for blunt vascular injuries . must be in stable condition .

must be ready for securing the airway .Laryngoscopy and Bronchoscopy   Strenghts : Direct visualization of larynx and trachea Weaknesses : Obscured by ETT .requires patient cooperation frequently sedation.

Doppler Ultrasound  Strengths : Noninvasive for carotid occlusion Weaknesses : operator dependent .inadequate with cervical immobilizations  . difficult with hematome and subcutaneous emphysema.unreliable for blunt carotid injury.

Angiography Strengths : Remain standard for vascular injuries Weaknesses : Invasive   .

water soluble inadequate Weaknesses : Technically difficult in the intubated patient  .Contrast Esophagogram  Strengths : Barium adequately distends Esophagus .

Flexible Esophagoscopy  Strengths : good visualization and safe in cervical immobilized patients Weaknesses : Difficult to adequately distend Esophagus to identify small injuries  .

Specific injuries     Carotid artery : direct blow or deceleration injury with surrounding hematoma or contusions. Can present with hemiparesis unexplained by brain CT Associated injury Full vascular work up .

Specific Injuries Cervical artery : Associated with flexion and rotation of the neck also C spine fracture Angiography is indicated   .

Specific injuries       Larynx and trachea : Direct blow Loss of anatomical contour Subcutaneous emphysema Patient position in patent airway Airway must be secured using tracheostomy .

Specific injuries Esophagus : Rare Direct blow Barium swallow and esophagoscopy     .

Conclusions     First priority is to secure the airway Not common but associated to high mortality and morbidity Neurologic deficit with normal brain CT needs Angiographic Examination Be aware of subtle signs .