Penetrating Neck TraumaDRADJAT 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 What’s 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 TraumaClinical 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

• Don’t blindly explore wound or clamp vessel

Penetrating Neck TraumaWorkup

• 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 TraumaCCH 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 Signs and symptoms

Vascular injury ShockHematoma

Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck Laryngotracheal injury Subcutaneous emphysema

Airway obstruction Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia

Pharynx/esophagus injury Subcutaneous emphysema Hematemesis Dysphagia or odynophagia

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• Patients taken to OR if clinical exam changes,

around 2% in most studies

Penetrating Neck TraumaManagement

• 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

Penetrating Neck TraumaFurther 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.

– 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 NeckEsophageal 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 NeckTracheal 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 NeckNeurologic 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 life-

threatening, missed esophageal injury causes late mortality

BLUNT NECK INJURYBLUNT NECK INJURY

Dradjat R SuardiDradjat R Suardi

IntroductionIntroduction

Infrequent except C-spineInfrequent except C-spine Awareness is essentialAwareness is essential Can be devastating even fatalCan be devastating even fatal Signs often subtle or absentSigns often subtle or absent Often too lateOften too late

Types of InjuryTypes of Injury

Direct impactDirect impact

Injury due to excessive extension , Injury due to excessive extension , flexion or rotationflexion or rotation

CompressionCompression

Initial evaluationInitial evaluation

Airway Airway Conscious patient : voice , stridorConscious patient : voice , stridor ETT is the route of choiceETT is the route of choice Tracheostomy when necessaryTracheostomy when necessary Be aware of obscured anatomic Be aware of obscured anatomic

landmarkslandmarks Best expertise availableBest expertise available

Initial evaluationInitial evaluation

BreathingBreathing Zona 1Zona 1 PneumothoraxPneumothorax PneumomediastinumPneumomediastinum

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

Physical examinationsPhysical examinations Inspection :Inspection : Evaluate the neck for lacerations , Evaluate the neck for lacerations ,

contusions , jugular venous distensioncontusions , jugular venous distension Laryngotracheal or aerodigestive injury Laryngotracheal or aerodigestive injury

(hoarseness,stridor,dysphagia)(hoarseness,stridor,dysphagia) Be aware of subtle signs such as simple Be aware of subtle signs such as simple

discolorations or minimal abrasionsdiscolorations or minimal abrasions

Physical examinationsPhysical examinationsAuscultations :Auscultations :Bruit over Carotid ArteryBruit over Carotid Artery

Palpations :Palpations :Pulse deficit or thrillsPulse deficit or thrillsStep off signStep off signAnatomical structure lossAnatomical structure lossSubcutaneous emphysemaSubcutaneous emphysema

Radiographic evaluationsRadiographic evaluations Lateral C spine X ray , CXRLateral C spine X ray , CXR Cervical immobilizations should Cervical immobilizations should

continue untill clinically and continue untill clinically and radiographycally clearedradiographycally cleared

Pretracheal soft tissue > 0,5 mm is Pretracheal soft tissue > 0,5 mm is suggestive C-spine fracturesuggestive C-spine fracture

Subcutaneous empysema , Subcutaneous empysema , retropharingeal airretropharingeal air

Diagnostic modalitiesDiagnostic modalities

CT scanCT scan Strengths : excellent for identifying Strengths : excellent for identifying

injuries to the larynx and vert.columninjuries to the larynx and vert.column Weakness : Not sensitive enough for Weakness : Not sensitive enough for

blunt vascular injuries , must be in blunt vascular injuries , must be in stable condition , requires IV stable condition , requires IV contratstcontratst

Laryngoscopy and Laryngoscopy and BronchoscopyBronchoscopy

Strenghts : Direct visualization of Strenghts : Direct visualization of larynx and trachealarynx and trachea

Weaknesses : Obscured by Weaknesses : Obscured by ETT ,requires patient cooperation ETT ,requires patient cooperation frequently sedation, must be ready frequently sedation, must be ready for securing the airwayfor securing the airway

Doppler UltrasoundDoppler Ultrasound Strengths : Noninvasive for carotid Strengths : Noninvasive for carotid

occlusionocclusion

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

AngiographyAngiography

Strengths : Remain standard for Strengths : Remain standard for vascular injuriesvascular injuries

Weaknesses : InvasiveWeaknesses : Invasive

Contrast EsophagogramContrast Esophagogram

Strengths : Barium adequately Strengths : Barium adequately distends Esophagus , water soluble distends Esophagus , water soluble inadequateinadequate

Weaknesses : Technically difficult in Weaknesses : Technically difficult in the intubated patientthe intubated patient

Flexible EsophagoscopyFlexible Esophagoscopy

Strengths : good visualization and Strengths : good visualization and safe in cervical immobilized patientssafe in cervical immobilized patients

Weaknesses : Difficult to adequately Weaknesses : Difficult to adequately distend Esophagus to identify small distend Esophagus to identify small injuriesinjuries

Specific injuriesSpecific injuries Carotid artery : direct blow or Carotid artery : direct blow or

deceleration injury with surrounding deceleration injury with surrounding hematoma or contusions. hematoma or contusions.

Can present with hemiparesis Can present with hemiparesis unexplained by brain CTunexplained by brain CT

Associated injuryAssociated injury Full vascular work upFull vascular work up

Specific InjuriesSpecific Injuries

Cervical artery : Associated with Cervical artery : Associated with flexion and rotation of the neck also flexion and rotation of the neck also C spine fractureC spine fracture

Angiography is indicatedAngiography is indicated

Specific injuriesSpecific injuries Larynx and trachea :Larynx and trachea : Direct blow Direct blow Loss of anatomical contourLoss of anatomical contour Subcutaneous emphysemaSubcutaneous emphysema Patient position in patent airwayPatient position in patent airway Airway must be secured using Airway must be secured using

tracheostomytracheostomy

Specific injuriesSpecific injuries

Esophagus : Esophagus : RareRare Direct blowDirect blow Barium swallow and esophagoscopyBarium swallow and esophagoscopy

ConclusionsConclusions First priority is to secure the airwayFirst priority is to secure the airway Not common but associated to high Not common but associated to high

mortality and morbiditymortality and morbidity Neurologic deficit with normal brain Neurologic deficit with normal brain

CT needs Angiographic ExaminationCT needs Angiographic Examination Be aware of subtle signsBe aware of subtle signs