Penetrating and Blunt Neck Injuries“Deadly Missed Injuries”

Bradley J. Phillips, MD

Burn-Trauma-ICUAdults & Pediatrics

Types of Injury - Penetrating

• 40% do not involve important structure

• GSW direct and delayed type of injury

• Structures– major vein 15-25%– major artery 10-15%– pharynx or esophagus 5-15%– larynx or trachea 4-12%– major nerves 3-8%

Type of Injury - Blunt

• Cervical spine

• Vascular injuries– internal carotid artery– vertebral carotid artery

• Aerodigestive– esophageal (rare)– larynx

Deadly Missed Neck Injuries

• Carotid Artery Injury

• Esophageal Perforation

• Laryngotracheal Injury

Diagnosis

• Significant injuries often asymptomatic– 25% positive symptoms and 25% positive signs– PE is often deceptively negative for severe injury

• Symptoms variable and delayed– internal carotid artery > 2 weeks– esophageal

• Weigelt (A J Surg 1987) 3/10 no signs or symptoms– laryngeal

• more likely to have presenting symptoms/signs• voice change, SOB, hemoptysis

Keys to Diagnosis

• Little need for labs

• High index of suspicion

• Sense of urgency

• Operation vs radiology

Case #1

• 21 yom with GSW to right neck without exit site

• c/o pain in throat/right neck• VS : HR 110, BP 130/70, RR 27 sats 98% (40%)

• PE: – mild swelling right neck, non-pulsetile

• ??

Penetrating Neck Zones

Vascular Injuries - Physical Exam

• Penetrating – Fogelman et al (Am J Surg,1956)

• 43% hemodynamically stable• 70% no sign of bleeding

– Carducci et al(Ann Emerg Med, 1985) • 1/3 no signs/symptom

– Apffelstaedt et al (World J Surg, 1994)• Prospective study, 335 patients• SW penetrating platysma• clinical signs absent 30% of positive neck explorations

Physical Exam - Penetrating

• Reliable for significant vascular injuries– Demetriades et al (Br J Surg, 1993)

• prospecitive 335 patients, detailed written protocol

• 7/335 required angiography

• 269/335 nonoperative managed– 2 required subsequent operations for vascular injury

– no complications

– Demetriades et al (World J Surg, 1996)• prospective 223 patients, strict written protocol(Doppler)

• 160/223 no clinical signs underwent angio– no vascular injury requiring treatment

Overview Management Penetrating Neck

• Zone I– routine angiography – ? Esophageal evaluation (EGD, swallow)– Airway evaluation (bronchoscopy)

• Zone II– selective management vs operative– neither approach superior (Asensio et al, Surg Clin N Amer, 1991)

• Zone III– routine angiography

Angiography

• Recommended in Zone I and III– difficult to assess clinically – difficulty surgical exploration

• Policy reduces nontherapeutic intervention• Costs (Demetriades et al, Br J Surg, 1993)

– Zone I only 5% required operation – Zone III only 13% required operation

Zone III GSW

Zone III GSW

Management Penetrating Zone II

• Mandatory exploration– Advantages

• decreased injuries– up to 25% unexpected injuries found

• low morbidity/mortality

– Disadvantages• report up 67% negative exploration

– Recommendations• Zone II injuries with/without instability• GSW that cross midline

Transcervical GSW

• More likely to involve vital structures– 73% vs 31% (GSW not cross midline)

• Hirshberg et al, Am J Surg 1994– retrospective 41 patients– 30(83%) positive for cervical injury– recommends mandatory exploration

• Demetriades et al, J of Trauma, 1997– prospective, 33 patients– 73% injury to vital organ, only 21% therapeutic

operation

Stab vs Gunshot Wounds

• Anecdotal suggestion– explore GSW, non-operative SW– not supported in literature

• Prospective study (Demetriades et al, Br J Surg, 1993)

– 97 GSW, 89 SW– GSW higher incidence of clinical signs than knives

(35% vs 19%)– GSW more likely injuries– therapeutic operation: GSW 16.5%, SW 10.1%

Zone II - “Selective Conservatism”

• If hemodynamically stable– angiography, contrast study, endoscopy , +/-

laryngoscopy• Exploration if positive study• Negative neck exploration 20%• Missed injuries negligible (Jurkovich et al, Trauma, 1985)• Disadvantages

– cost and time– iatrogenic (CVA, esophageal perfs)

Acute Management Zone II Injury

Treatment- Specific Injuries

• Carotid injuries– 22% of penetrating cervical vascular injuries – mortality 10-20% (in-hospital)– Repair vs ligation

• repair if possible in absence of neurologic deficits

• prefer saphenous vein, but prosthetics ok

• if internal carotid injuries, transposition of external carotid

• ligation in neurologically intact for high internal carotid injury if very difficult or impossible

Treatment- Specific Injuries

• Carotid injury– Presence of neurologic deficits

• controversial

• ? Concern of postvascularization hemorrhagic infarct

• increased risk if evidence of sever anemic infarct or edema

• recommend repair– if deficits are short of coma

– no evidence of anemic infarct

– patent distal carotid

Treatment- Specific Injuries

• Carotid artery occlusion with symptoms– may result in late local or neurologic complications– may develop pseudoaneurysm or rupture– recommend repair if

• technically feasible

• not at base of skull

Carotid Intimal Flap

Treatment - Specific Injuries

• Minor carotid injuries (intimal flaps)– natural history not known– controversial: observation vs aggressive approach– ? role of duplex for decision making– role of anti-platelet unproven, but used

Vertebral Artery Pseudoaneurysm

Management - Specific Injuries

• Vertebral artery– increased frequency secondary liberal angio– 10% of major vascular injuries– 67% have association with major cervical injury

mainly spine– isolate injury asymptomatic in 1/3 patients– thrombosis rarely lead to neurologic sequelae– angiographic embolization standard of care if

bleeding

Complications

• Nonoperative Management– delayed bleeding– CVA (dissection, emboli)– pseudoaneurysm– sepsis (missed esophageal leak)

• Operative Management– injury to nerves (vagus, hypoglossal, recurrent)– blood loss– missed injury (particularly esophageal)

Summary Treatment - Vascular Injury

• Surgical exploration unstable and stable Zone II (board answer)

• Angiography Zone I and III• ? Nonoperative management stable Zone II

– depends on expertise and facilities

• Other interventions– embolization high carotid or vertebral artery– endovascular stent (pseudoaneurysms)– anticoagulation blunt carotid/vertebral artery

Case #2

• 56 yom s/p MVC driver vs pole

• Found unconscious at scene, intubated

• VS: HR 90, BP 110/80, sat 100%

• PE: – abrasions to left shoulder/mid chest/LUQ – GCS 7, pupil equal/reactive

• ??

Carotid Artery Dissection Internal Carotid Occlusion

Blunt Carotid Injury

• Low incidence (0.08-0.25%)• Male 76%, Mean age 35 +/- 2 yrs• Most commonly intimal disruption• ? asymptomatic

– Louisville U. (1998) 24 BCI all symptomatic– Colorado U. (1998) 12/56 asymptomatic

• Often delayed diagnosis (Krajewski, Ann Surg 1980)– 58% > 10hrs– 36% > 24 hrs

Blunt Carotid Injury

• Eiology– MVC 41% (seat belt not a

factor)

– Fall/ped struck 14%

– MCC 11%

– other 22%

• ski

• bike

• assault

• near hanging

• horseback

• Associated injuries– CHI 65%– facial fx 60%– thoracic 51%– basilar skull fx 32%– extremity fx 32%– abdominal 30%– pelvic fx 16%– cervical fx 5%– none 16%

Biffl et al, Ann Surg, 1998

Diagnosis - Vascular Injury

• Careful PE– hematomas, bruit, thrill

– Horner’s syndrome

– limb paresis or paralysis

– deep coma

• Delayed up to several days• PITFALL: Failure to consider blunt carotid

injury with negative CT and CNS changes delayed

Blunt Carotid Injury

• Screening asymptomatic (Biffl et al, 1998)– severe neck hyperflexion, flexion, or rotation – significant soft-tissue injury anterior neck– cervical spine fracture– displaced midface fx or mandibular fx associated

with a major injury mechanism– basilar skull fx involving

sphenoid/mastoid/petrous/foramen lacerum

Blunt Carotid Injury

• Biffl et al, 1998 (continued)– before screening 12/12429 (0.1%)– after screening 25/2902 (0.86%)

• only 28% had lateralizing signs/symptoms

• 25% had concomitant head injury/depressed MS

– symptoms and timing• > 24 hrs - 28%

• > 1 week - 8.3 %

Blunt Carotid Injury

• Biffl et al, 1998 (continued)– Outcome by symptoms at diagnosis

Dead Major Minor Normal

Asymptomatic 1 1 0 11

Symptomatic 7 6 5 6

Blunt Carotid Injury

• Biffl et al, 1998– Treatment

• Operative =1/37• Anticoagulation = 24/37

– endovascular stent 10/24

• No intervention = 11/37

– Outcome Dead Major Minor Normal Anticoagulation 1 6 4 13 No Anticoagulation 3 1 1 4

Blunt Carotid Injury

• Biffl et al, 1998– Complications

• angiography (2) - groin hematoma(1), CVA (1)• hemorrhagic

– 54% rebleeding ( transfusions and/or cessation)

– Summary• Anticoagulation improves outcome

– confirmed Fabian et al, Ann Surg, 1996

• Aggressive screening ( ? Diagnostic test)• Optimal intervention ?• Stenting pseudoaneurysm

Blunt Carotid Injury

Contraindicaton to Heparin

No Yes

Heparin Observe

Angiography 7-10 d Pseudoaneurysm

No Yes

Coumadin 3 mos Heparin/Stent or OR

Vascular Injury - Radiologic Test

• C- spine films– r/o fractures (spine/larynx)– ? subcutaneous air– anterior cervical soft tissue swelling– tracheal deviation

• ? CXR/ skull xray (where’s the bullet ?)

BCI and Anticoagulation

Fabien et al, Surg, 1996

Vascular Injury - Radiologic Test

• Duplex– can be used for carotid injuries Zone II only

– as useful as angio in stable patients with Zone II injury (Thal, Trauma, 1991)

• operator dependent

• CT Angiogram– limited studies

– ? comparable to angiogram (missed blunt injuries)

– advantage: no risk of CVA

Vascular Injury - Radiologic Test

• Angiography– gold standard (4 vessel runoff)– Indications

• proximity to carotid with or without hematoma

• shotgun blasts with ? multiple artery segments injuries

• precise localization for planning proximal or high carotid injury

• blunt trauma with extensive soft-tissue injury

• blunt trauma with neurologic loss unexplained by CT

Case #3

• 29 yof restrained driver, head-on MVC

• reported striking face/neck on steering wheel c/o neck/throat pain

• airway patent without voice change

• PE: – anterior neck crepitus– no stridor

• ??

Diagnosis - Esophageal

• Blunt esophageal injury rare

• High index of suspicion in blunt trauma

• Penetrating trauma - evaluation part of a complete work-up

• If missed, high morbidity/mortality

GSW Anterior-Posterior Neck

Esophageal Injury - Diagnostic Test

• Contrast swallow– Extravasation is diagnostic– Negative study is not reliable (particular in neck

with gastrograffin)– 50% of leaks missed with gastrograffin– 25% of leaks missed with barium

Gastrograffin swallow

Esophageal Injury - Diagnostic Tests

• Controversy of initial contrast to use– gastrograffin

• pneumonitis if aspirated

– barium• increased inflammation/infection in the mediastium

• Rec: If gastrograffin study is negative, repeat swallow this barium. Avoid gastrograffin in patients without gag/cough

Esophageal Injury - Diagnostic Test

• Endoscopy– Generally recommended when contrast swallow is

negative, but suspicion is high

– Perforations often readily seen, however• 50% missed (Weigelt et al Am J Surg 1987)

• missed in pharynx and cervical esophagus

• missed in patients on ventilator (poor expansion of esophagus)

• Combination of swallow/esophagoscopy reduces missed injuries to < 5%

Treatment - Esophageal Injury

• Negative studies/high suspicion– 24 hr observation

• Pharyngeal– usually non-operative– NPO/IV Abx

• Esophageal– resection– ? diversion

Laryngotracheal Injury

• Larynx extends from epiglottis opposite C3 to cricoid cartilages at level C6

• Cervical trachea cricoid to thoracic inlet

• Injury– penetrating– blunt

Penetrating Laryngotracheal Trauma

• 5-15% of penetrating neck trauma– larynx 33%– cervical trachea 67%

• Doubled if esophagus injury

• 25% of airway injuries have esophageal injury

Blunt Laryngotracheal Injury

• Most common cause is MVC – hitting steering wheel or dashboard– “clothesline” with ATV/snowmobile

• Endotracheal intubation– arytenoid subluxtion– recurrent nerve paralysis (balloon overinflation)

Thyroid Fracture

Diagnosis - Laryngotracheal Injury

• Pathology– subglottic/supraglottic submucosa edema/air– usually occurs within 6 hours– > 70% cross-sectional area reduced before

symptoms• Associated with cervical spine injury• Voice change most common• Other S/S: dyspnea, pain, score throat, dysphagia,

odynophagia, hemoptysis, subcutaneous air

Diagnosis - Laryngotracheal Injury

• Plain xrays– soft tissue emphysema

– airway compression

– fracture of laryngeal cartilages

• CT scan– detailed and accurate appraisal

• Endoscopy– Flexible vs rigid

– Bronchoscopy/laryngoscopy 100% accurate

Management of Laryngotracheal Injury

• Airway control• Preparation for surgical airway• Non-operatively if,

– clinically stable airway

– endoscopy shows no displaced cartilages, mucosal disruptions or progressive edema/hematoma

– therapy• semi-fowler position, humidified air, steroids, IV abx

• Operative– tracheostomy if airway unstable– no advantage in delay > 24 hrs to repair fx– laryngeal fractures

• thyroid fx most common

• reduction and fixation with stainless +steel sutures

• delay of reduction > 7-10, scarring makes it more difficult and return of normal function unlikely

Management of Laryngotracheal Injury

Outcomes of Laryngotracheal Injury

• 1/3 of patients who survive airway injury reach hospital alive suffer delay in diagnosis and treatment

• preventable death in 10% in upper airway trauma (most secondary to delay)

• most have some permanent voice and airway impairment or tendency to aspirate

• problems most significant after blunt injury and penetrating (more extensive damage)

Errors in Management of Laryngeal Trauma

• Assuming airway problem in unconscious patient is only due to prolapse of the tongue

• attempting blind intubation in suspected larygneal injury

• inserting ET tube with force is through vocal cords and fails to advance

• use of muscle relaxation in a patient with a possible cricotracheal separation

• Inadequate assessment of esophageal injury