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 InjuriesNeck trauma mechanisms:

blunt

penetrating : 5-10% of all trauma cases

The types of injuries:

airway (laryngotracheal),

digestive tract (pharyngoesophageal),

vascular system

neurologic system

PENETRATING INJURIESStab 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 (multibleintubation attempts might enlarge a pyriformsinus laceration/ tracheal tear may be exaceratedby 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,activebleeding,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

Advantages

•Superior image quality

•Readily available, quick

•Limited interuservariability

•Safe

•Shows surrounding structures

Limitations

Poor timing of contrast load

Patient movement

Metallic artifact

• Not therapeutic

Angiography

In zone I and zone III : routinely

When b/l neck involved, 4 vessel angiography : b/lcarotid 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 haemodynamicinstability, haemomediastinum, hemothorax, hypovolemic shock

Selective exploration

Hemodynamically stable, non life threatening injuries, Can undergo imaging investigations.

SELECTIVE VS MANADATORY NECK EXPLORATION

Exploration of Neckgeneral 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

• Zone I - SCM incision + sternotomy

• Zone II - SCM incision

• Zone III - post-auricular extension with SCM incision + mandibular subluxation

Operative Approach

• 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

SCM Incision

• 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%

Cervical Vascular Injuries

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

• 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

Management

• 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

Disadvantage