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 %

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

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

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

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

Penetrating Neck Trauma

Whats at risk?
Lots of structures!
Carotid artery (Zone 1,2,3) Vertebral artery (Zone 1,2,3) Spinal Cord (Zone I,2,3) 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)

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

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

Ballistics
Over 95% of penetrating neck wounds are from guns and knives, remainder from motor vehicle, 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, and the kinetic energy of any exiting fragments or projectiles The velocity of the projectile is the most significant aspect of energy transfer (K.E. = 1/2 mv^2

Ballistic cont...
Muzzle velocity less than 1000 ft/s is considered low velocity .22 and .38 caliber handguns have a velocity of 800 ft/sec .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.
Injuries inflicted with high power rifles, shotguns at less than 20 feet, and .357 and .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 -- the subclavian vein is at high risk

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

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

Physical Examination

Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits Neuro exam: mental status, cranial nerves, and spinal column Examine the chest, abdomen, and extremities Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here Dont blindly explore wound or clamp vessel

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

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

Preoperative Preparation
Surgeon and staff ready for emergent/urgent tracheotomy Gentle cleansing of wound, betadine paint only Prep vein donor site, 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

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, maybe No increase in mortality when adjunctive diagnostic studies and serial exams performed

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 IVs on non-injured side ED thoracotomy and aspiration of right ventricle for venous air embolism if
Sudden cardiopulmonary arrest Profound hypotension unresponsive to fluids

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 cant use it? Nasotracheal intubation, fiberoptic laryngoscopy and other difficult airway devices are unlikely to be helpful. 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 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!

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

Site/Zone II
Few injuries will escape clinical examination Most carotid injuries occur here Adjunctive studies, except barium swallow and esophagoscopy where indicated, 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

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 - such as in a rural setting

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

Airway
DL where laryngeal injury is suspected Mucosal tears are closed with absorbable sutures Cover raw surfaces with nasal, buccal, 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

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.
When tension is required, 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

Penetrating Trauma Neck

Neurologic Injury Several neurologic structures vulnerable in neck
Spinal cord
Complete cord injury Incomplete injury
Brown-Sequard syndrome Ipsilateral hemiplegia, contralateral sensory deficit

Brachial plexus Peripheral nerve roots Cranial nerves VII,IX,X,XI,XII

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, missed esophageal injury causes late mortality

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

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

Physical examinations

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

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

Radiographic evaluations

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

Diagnostic modalities

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

Laryngoscopy and Bronchoscopy

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

Doppler Ultrasound

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

Angiography
Strengths : Remain standard for vascular injuries Weaknesses : Invasive

Contrast Esophagogram

Strengths : Barium adequately distends Esophagus , water soluble inadequate Weaknesses : Technically difficult in the intubated patient

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