Neck trauma

1

Neck trauma

Done by:Dr. ahmad m. aldhafeeriR1. ORL-H&N surgery

dr.ahmad aldhafeeri 2



Type of neck injury

- Penetrating

Gunshot wound

Stab wound

- Blunt

MVA

Sport injury

Strangulation

Blows



• Zone III


۞ Zone I ۞ Bound superiorly by the cricoid and

inferiorly by the sternum and clavicles

- The great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, and jugular veins),

- Aortic arch

- Trachea

- Esophagus

- Lung apices


۞ZONE II ۞Bound inferiorly by the cricoid and

superiorly by the angle of the mandible

- Carotid and vertebral arteries

- Jugular veins

- Pharynx, Larynx, Trachea

- Esophagus, base of the tunge

- Phrenic , vagus , and hypoglossal nerves

۩ Injuries here are seldom occult

۩ Common site of carotid injury


۞ZONE III ۞ Lies above the angle of the

mandible

- Carotid arteries

- Jugular veins

- The salivary and parotid glands

- Esophagus, pharynx - Major cranial nerves

۩ Vascular and cranial nerve injuries common


morbidity and mortality

• Zone I injuries are associated with the highest morbidity and mortality rates.

• more common among males than females.

• Most are adolescents and young adults


• Neck trauma accounts for 5-10% of all serious traumatic injuries

• missed cervical injuries secondary to neck trauma result in a mortality rate of greater than 15%.

• 10% of neck wounds lead to respiratory compromise. Loss of the airway patency may occur precipitously, resulting in mortality rates as high as 33%.


Frequancy

• Thrombosis is the most common complication of vessel injury, occurring in 25-40%

• the most common sites of vascular injuries internal jugular vein (9%) and carotid artery (7%).

• Injury to the pharynx or the esophagus occurs in 5-15% of cases.

• The larynx or the trachea is injured in 4-12% of cases.

• Major nerve injury occurs in 3-8% of patients sustaining penetrating neck trauma.


Vascular injury

• Hard evidence:

sever active hemorrhage, shock unresponsive to volume expansion, absent ipsilateral upper extremity, neurologic deficit

• Soft evidence:

bruit, widened mediastinum , hematoma

Decreased upper extremity pulse, shock response to volume expansion


Laryngotracheal injury

Subcutaneous emphysemaAirway obstructionSucking woundStridorDyspneaHemoptysisHoarsenessDysphonia


Pharynx/esophagus injury

Subcutaneous emphysema,

Hematemesis

Dysphagia

Odynophagia


Approach &

Management


Primary survey


• Established Airway• be prepared to obtain an airway

emergently• intubation or cricothyrotomy• Be a ware of cutting the neck in the

region of the hematoma -- disruption there may lead to massive bleeding

• must assume cervical spine injury until proven otherwise

Airway


• Zone I injuries with concomitant thoracic injuries• pneumothorax• hemopneumothorax• tension pneumothorax

Breathing


• 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• Do not remove objects protruding from the

neck in the ER

Circulation


• Cross-match, hematologic analysis, chemistries, urinalysis, coagulation profile, blood gas, toxicologic analysis

• B-hCG for female • Urine cath.• CXR – inspiratory /expiratory films to

assess the lung, mediastinum and any phrenic nerve injury

• Cervical spine film to rule out fractures• Soft tissue neck films AP and Lateral• Arteriograms, contrast studies as indicated


• Obtain from any witnesses or 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

Secondary survey


• 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

• Don’t blindly explore wound or clamp vessel

examination



Zone I

• Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy

• suspicion must be great before taking the patient to OR because high mortality rate.

• Cardiothoracic surgery consultation a must• 4 vessel Angiography is advocated by

surgeon because difficulty of identify injury intraoperative

• 2 prospective study show only 5% of zone I injury need operation


Zone II

• Few injuries will escape clinical examination

• Most carotid injuries occur here• algoriyhm • *Several study have suggest of contrast

enhance CT to demonstrate the injury and aid for further invasive investigation or exploration

• *Furthermore studies shown CT angio. More to be useful and comparable to conventional angiography in evaluation vascular inj.


• *Finally some expert recommend ipsilateral exploration despite increase incidence of negative exploration and increase hospital cost

• None of these algorithm for management of penetrating zone II had shown superiority over the others*


Zone III

• Upper neck injury with evidence of vascular injury required prompt CT angiography

• Embolotherapy can be used for temporary or definitive management except for Ica

• Direct pharyngoscopy suffice to exclude aerodigestive trauma

• Endovascular stenting or embolization especially in zone I & III should be considered


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


*Exploration • Most common approach in anterior of

SCM• Collar incision is reversed for isolated

aerodigestive inj. Or for bilateral exploration

• Major arteries should be repaired where possible except the vertebral which can be ligated

• Veins can be ligated EXCEPT bilateral IJV


• 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


Aerodigestive injury in EXPLORATION

• DL where laryngeal injury is suspected

• Aerodigestive should repaired primary by synthetic absorbable suture

• IF tandem injury occur a well vascularized flap should be interpose between the repairs to prevent aerodigestive fistula

•


• Drain-if suspect aerodigestive injury

To Prevent lethal mediastinitis

and In combined aerodigestive and vascular injuries the aerodigestive repair should be drained to the contralateral neck to prevent break down of the vascular repair from gastrointestinal secretion

• raw surfaces Cover with nasal, buccal, or local mucosal flap

• A keel or soft stent is placed when loss areas are opposed


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


Blunt neck trauma

• Sever Blunt neck trauma can result in significant laryngeal and vascular injury

• Best modality in stable pt contrast enhance CT to demonstrate the injury and aid for further invasive investigation or exploration


laryngeal injury

• If suspect of minor laryngeal injury can treated with airway protection, head of bed elevation and possibly antibiotics

• Major laryngeal injury required operative exploration and repaired


Blunt vascular injury

• Usually involves the internal and common carotid artery

• there may also be injury to the vertebral vessels without symptomatology & come later with neurological deficit

• Four vessels angiography and CT angiography are preferred diagnostic modalities

• Severity of the deficits and time of diagnosis are strongly associated with outcome


• The current recommendation is for operative repair for surgically accessible lesions.

• Systemic Anticoagulant with heparin appears to improve neurologic outcome and is therefore recommended for surgically inaccessible lesions


• If suspect esophagial injury

ESOPHAGOSCOPY /ESOPHAGOGRAM

If +ve operation exploration ‘ll next step


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 studies will avoid missed injuries

• Arteriography for zone I and zone III injuries

• Vascular injuries most immediately life-threatening & missed esophageal injury causes late mortality


THANK YOU

Health & Medicine

Neck trauma