Penetrating Neck Injuries Penetrating Neck Injuries (PNI)(PNI)JHSGR 22 Oct 2011JHSGR 22 Oct 2011
Stephanie HY LauQueen Elizabeth Hospital
The NeckThe Neck
Vital structures in Vital structures in close proximityclose proximity
Single traumatic Single traumatic event can lead to event can lead to multi-system multi-system injuriesinjuries
IncidenceIncidence
In USA:
1% of all trauma patients
Brywczynski JJ et al. Management of penetrating neck injury in the emergency Brywczynski JJ et al. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J 2008; 25: 711-715department: a structured literature review. Emerg Med J 2008; 25: 711-715
Timely Management is Timely Management is CriticalCritical
Exsanguination and Exsanguination and airway obstruction airway obstruction most common most common
Mortality for major Mortality for major vascular injuries vascular injuries can reach 50%can reach 50%
Delay can result in Delay can result in devastating devastating outcomeoutcome
Three Anatomical ZonesThree Anatomical Zones
Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4
Three Anatomical ZonesThree Anatomical Zones
Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4
Zone IZone I
Three Anatomical ZonesThree Anatomical Zones
Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4
Zone IIZone II
Three Anatomical ZonesThree Anatomical Zones
Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4
Zone IIIZone III
Crossing ZonesCrossing Zones
Zone boundaries Zone boundaries can be can be transgressedtransgressed
Superficial wound Superficial wound does not does not correspond well to correspond well to deeper structures deeper structures injuredinjured
AirwayAirwaySecuring the airway is the first Securing the airway is the first and most important stepand most important step
Definitive airway advocated in Definitive airway advocated in significant injuries or significant injuries or respiratory difficulty respiratory difficulty
Orotracheal intubation is Orotracheal intubation is primary approach unless primary approach unless contraindicatedcontraindicated
Double set up for surgical Double set up for surgical airway airway
Control BleedingControl Bleeding
Do not explore wounds Do not explore wounds in the ED in the ED
Apply direct pressure to Apply direct pressure to bleeding woundsbleeding wounds
Foley catheter can be Foley catheter can be inserted into wound for inserted into wound for tamponade effecttamponade effect
C-Spine Immobilization?C-Spine Immobilization?
Eastern Association for the Surgery of Trauma (EAST) Practice guidelinesEastern Association for the Surgery of Trauma (EAST) Practice guidelinesBrywczynski JJ et al. Management of penetrating neck injury in the emergency department. Em Med J Brywczynski JJ et al. Management of penetrating neck injury in the emergency department. Em Med J 2008; 25:711-52008; 25:711-5
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Hemodynamic instability or Hemodynamic instability or ““Hard Hard SignsSigns””
•Active bleedingActive bleeding•Expanding or pulsatile haematomaExpanding or pulsatile haematoma•Absent carotid pulse, neck bruit or Absent carotid pulse, neck bruit or thrillthrill•Subcutaneous emphysema, Subcutaneous emphysema, hoarseness or dysphagiahoarseness or dysphagia•Air bubbling from woundAir bubbling from wound•Evolving strokeEvolving stroke
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Immediate Immediate ExplorationExploration
Neck ExplorationNeck Exploration
Incision along Incision along anterior border of anterior border of
SCMSCM
Extension - Median Extension - Median SternotomySternotomy
Most versatile incision for Zone I injuries
Extension - Median Extension - Median SternotomySternotomy
+ Supraclavicular lateral extension to reach most major vessels
Extension - Median Extension - Median SternotomySternotomy
+ Anterior left 3rd intercostal space thoracotomy to expose L subclavian and descending aorta
Vascular Injuries - Carotid Vascular Injuries - Carotid a.a.
Best treated by surgical repairBest treated by surgical repair
Proximal internal carotid injuries not Proximal internal carotid injuries not amenable to repairamenable to repair
Ligation of proximal external carotid and Ligation of proximal external carotid and utilization of it as a conduit for restoration of utilization of it as a conduit for restoration of internal carotid flowinternal carotid flow
Ligation reserved only for those with Ligation reserved only for those with devastating neurological injuriesdevastating neurological injuries
Liekweg and Greenfield Unger et al, Brown et al
Vascular Injuries - Vertebral Vascular Injuries - Vertebral a.a.
Rare, generally well tolerated due to Rare, generally well tolerated due to excellent posterior circulationexcellent posterior circulation
Operative repair is difficultOperative repair is difficult
Best treatment option: proximal and distal Best treatment option: proximal and distal ligation or embolizationligation or embolization
Vascular Injuries - Vascular Injuries - VenousVenous
Ligation if injury beyond repair by simple Ligation if injury beyond repair by simple lateral venorrhaphylateral venorrhaphy
Repair for bilateral internal jugular or Repair for bilateral internal jugular or brachiocephalic venous injurybrachiocephalic venous injury
Bilateral ligation causes increased Bilateral ligation causes increased venous pressure and can worsen venous pressure and can worsen cerebral edemacerebral edema
Laryngotracheal InjuriesLaryngotracheal Injuries
Minor injuriesMinor injuries
Observed for 24 hours Observed for 24 hours
Head of bed elevation + anti-reflux medicationHead of bed elevation + anti-reflux medication
Severe injuries (mucosal lacerations, exposed Severe injuries (mucosal lacerations, exposed cartilage, displaced fractures or unstable cartilage, displaced fractures or unstable cartilaginous skeleton)cartilaginous skeleton)
Primary repair with precise reduction and Primary repair with precise reduction and restoration of laryngeal architecturerestoration of laryngeal architecture
Pharyngoesophageal Pharyngoesophageal InjuriesInjuries
Pharyngeal lesionsPharyngeal lesions
Simple primary repair and Simple primary repair and drainagedrainage
Pyriform sinus, cricopharyngeus Pyriform sinus, cricopharyngeus and esophagusand esophagus
Primary 2-layer closure and Primary 2-layer closure and muscle flap for coveragemuscle flap for coverage
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Zone I and III InjuriesZone I and III InjuriesDifficult surgical accessDifficult surgical access
Routine workup with angiogram + esophageal Routine workup with angiogram + esophageal workupworkup
Zone I patients: Additional bronchoscopy Zone I patients: Additional bronchoscopy
Rule out occult injuriesRule out occult injuries
PositivePositive
Useful to decide incision (Zone I) and to Useful to decide incision (Zone I) and to consider endoluminal intervention (Zone III)consider endoluminal intervention (Zone III)
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Zone II InjuriesZone II Injuries
SymptomaticSymptomatic
Surgical exploration with pre-operative Surgical exploration with pre-operative angiogramangiogram
Penetrating Neck Penetrating Neck InjuriesInjuries
Penetrating Neck Penetrating Neck InjuriesInjuries
StableStableStableStableUnstableUnstable““Hard SignsHard Signs””
UnstableUnstable““Hard SignsHard Signs””
Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III
SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc
AsymptomatiAsymptomaticc
CTACTACTACTA
Surgical Surgical explorationexploration
Surgical Surgical explorationexploration
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +
BronchoscopyBronchoscopy
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
Surgical Surgical exploration exploration (Thoracic)(Thoracic)
DischargeDischargeDischargeDischarge
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
Routine CTA Routine CTA and and
esophageal esophageal workupworkup
IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy
Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration
Selective Selective explorationexplorationSelective Selective
explorationexploration
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine CTA Routine CTA + esophageal + esophageal
workupworkup
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Routine esophageal Routine esophageal workup + workup +
Observation + serial Observation + serial examinationexamination
Should We Explore All Should We Explore All Asymptomatic Zone II Asymptomatic Zone II Injuries?Injuries?
Historical BackgroundHistorical Background
Before 1950s: Conservative managementBefore 1950s: Conservative management
1950s: Mandatory exploration1950s: Mandatory exploration
Reduction of mortality from 15% to 5% during WWIIReduction of mortality from 15% to 5% during WWII
60% negative exploration although with low morbidity60% negative exploration although with low morbidity
1980s: Selective exploration 1980s: Selective exploration
Availability of additional investigationsAvailability of additional investigations
Similar morbidity and mortality, avoids unnecessary explorationSimilar morbidity and mortality, avoids unnecessary exploration
Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.Biffl WL et al 1997: 18 year prospective study showed selective management of PNI safeBiffl WL et al 1997: 18 year prospective study showed selective management of PNI safe
Additional InvestigationsAdditional Investigations
Esophageal InjuriesEsophageal Injuries
Esophagography with water-soluble contrastEsophagography with water-soluble contrast
85% sensitivity and specificity85% sensitivity and specificity
Increased to near 100% by addition of Increased to near 100% by addition of esophagoscopyesophagoscopy
Vascular InjuriesVascular Injuries
CT angiogramCT angiogram
Leonard JW et al. Penetrating Neck Injuries: Diagnosis and Selective Management. Current Leonard JW et al. Penetrating Neck Injuries: Diagnosis and Selective Management. Current Therapy of Trauma and Surgical Critical CareTherapy of Trauma and Surgical Critical Care
Shift of ParadigmShift of ParadigmFrom era of mandatory exploration to From era of mandatory exploration to more selective managementmore selective management
Mandatory ExplorationMandatory Exploration
Still a safe diagnostic and therapeutic Still a safe diagnostic and therapeutic option if additional evaluation or option if additional evaluation or observation is not feasibleobservation is not feasible
SummarySummary
PNI often leads to multi-system injuries PNI often leads to multi-system injuries with significant morbidity and mortality with significant morbidity and mortality due to close proximity of vital structuresdue to close proximity of vital structures
Initial management follows standard ATLS Initial management follows standard ATLS protocolprotocol
SummarySummary
Unstable patients require immediate explorationUnstable patients require immediate exploration
Formal exploration used to be mandatory for all Formal exploration used to be mandatory for all Zone II injuriesZone II injuries
With advancement in diagnostic studies, stable With advancement in diagnostic studies, stable and asymptomatic patients can now be further and asymptomatic patients can now be further evaluatedevaluated
Delineate sites of injuryDelineate sites of injury
Facilitate planning of surgical or IR approachFacilitate planning of surgical or IR approach
Avoid missing significant injuries and to prevent unnecessary Avoid missing significant injuries and to prevent unnecessary explorationexploration