Transcript Blunt and penetrating neck injury

Blunt and penetrating neck injury
reference
 B.J.Bailey ,et al. Head & Neck surgery
Otolaryngology.4th edition.2006
 Charles W. Cummings, et al, Cummings
Otolaryngology, Head & Neck Surgery, 5th ed.
2010
 D.V. Feliciano ,et al. Trauma, 6th Edition.2008
 www.google.com
Zones of the Neck
.
Zone I: thoracic inlet to
cricoid cartilage
Zone II: cricoid cartilage
to the angle of mandible
Zone III: angle of the
mandible to skull base
CLASSIFICATION
Zone I
From the clavicles to the cricoid
 Trachea
 Lungs
 Proximal carotid and vertebral arteries
 Jugular veins
 Thoracic Vessels
 Esophagus
 Superior Mediastinum
 Thoracic Duct
 Spinal Cord
 Brachial Plexus
Zone II
From cricoid to angle of mandible
 Trachea
 Larynx
 Carotid and vertebral aa.
 Jugular Vein
 Esophagus
 Spinal Cord
Zone III
Angle of mandible to base of skull
 Distal carotid and vertebral arteries
 Pharynx
 Spinal cord
PENETRATING NECK TRAUMA
 Presently, penetrating neck injury comprises 5% to 10% of
all trauma cases.
 All penetrating neck wounds are potentially dangerous and
require emergency treatment.
Physical properties of penetrating
objects
 handgun
 Rifle
 Shotguns
 Knife and stab injuries
Physical properties of penetrating
objects
 Kinetic energy= ½ mv2
 m = mass
 V = velocity
 Degree of wound
 Firearm
 Low velocity ( < 1,000 ft/sec)  handgun 300-800 ft/sec
 high velocity ( > 1,000 ft/sec)  shotgun 1,200 ft/sec , rifle 2,200
ft/sec
Physical properties of penetrating
objects
 Gunshot wound  tissue
injury from 2 mechanism
 Direct tissue injury
 Temporary caviation
 Low velocity tissue
damage
 High velocity  tissue loss
KNIFE and STAB
 Knife, ice-pick, cut-glass, or razor-blade
 more predictable pathways
 single-entry wound may be from multiple stab wounds
 cervical stab wounds have a higher incidence of subclavian
vessel laceration because stabbings to the neck often occur in
a downward direction with the knife slipping over the
clavicle and into the subclavian vessels.
 spinal injuries, neck stab wounds have a lower incidence than
cervical bullet wounds.
Genaral trauma principle
 A : airway with C-spine control
 B : breathing and ventilation
 C : circulation
 D : disability and neurologic status
 E : exposure and evaluation other injury
A : Airway
 Most casecarefully
intubated transorally
 If C –spine injury is
suspected intubate with
neck stabilized
 Unstable airway with sig.
bleed or edema in oral
cavity or pharynx
cricothyroidotomy or
urgent tracheostomy
A : Airway
 Multiple blind intubation attempts will risk enlarging a
lacerated piriform sinus wound and extending it
iatrogenically into the mediastinum.
 Tracheal tear may be exacerbated by extending the neck
A : Airway
 Obvious tracheal injury
carefully intubated
through entry wound using
armored/reinforced ETT
B: Breathing
 Administer high-flow oxygen
 Monitor : pulse oximetry
 Difficulty ventilation may
upper airway or thoracic
injury
 Unequal breath sounds &
asymmetric chest
movement inadequate
ventilation
 Pneumothorax
 Hemothorax
 Tension pneumothorax
C : Circulation
 Control active bleeding with
direct pressure
 Do not clamp bleeding
vessels
 Subsequent injury to vascular or
nervous structure
 Avoid placing IV access at a
location where the IV fluid
would flow toward the site of
injury
 Avoid inserting NG tube at the
initial resuscitation : gag &
retching cause dislodge a clot &
cause hemorrhage
D : Disability
 Neurodeficit indicate
 directed nerve or spinal
cord injury
 cerebral ischemia cause by
carotid artery injury
 Need rapid sedation and
paralysis for intubation
 Immobilize the cervical
spine in a neutral position
Vital structures of the neck
 four groups:
 the air passages (trachea, larynx, pharynx, lung);
 vascular (carotid, jugular, subclavian, innominate, aortic arch
vessels);
 gastrointestinal (pharynx, esophagus)
 neurologic (spinal cord, brachial plexus, peripheral nerves,
cranial nerves [CNs])
SYMPTOM
 Airway
 Vascular System
 Reparatory distress
 Hematoma
 Stridor
 Persistent bleeding
 Hemoptysis
 Neurologic deficit
 Hoarseness
 Absent pulse
 Tracheal deviation
 Hypovolemic shock
 Subcutaneous emphysema
 Bruit
 Sucking wound
 Thrill
 Change of sensorium
From Stiernberg C, Jahrsdoerfer RA, Gillenwater A, et al. Gunshot wounds to the head and neck. Arch
Otolaryngol Head Neck Surg. 1992;118:592
SYMPTOM
 Nervous System

Hemiplegia
Quadriplegia
Coma
Cranial nerve deficit
Change of sensorium
Hoarseness
 Esophagus/Hypopharynx

Subcutaneous
emphysema
Dysphagia
Odynophagia
Hematemesis
Hemoptysis
Tachycardia
Fever
From Stiernberg C, Jahrsdoerfer RA, Gillenwater A, et al. Gunshot wounds to the head and neck. Arch
Otolaryngol Head Neck Surg. 1992;118:592
Mandatory versus Elective Exploration
 Immediately life threatening: massive bleeding, expanding
hematoma, hemodynamic instability, hemomediastinum,
hemothorax, and hypovolemic shock.Immediate surgical
exploration
 Hemodynamically stable ,non–life-threatening features can
undergo thorough imaging investigations to determine the
extent of injury.
Injury
Zone 1 injury
 Below cricoid, dangerous
area
 Protect zone  bony thorax
and clavicle
 Motality rate 12 %
 Potential for injury to great
vessel and mediastinum
 Mandatory exploration : not
recommend
 Angiography and esophageal
evaluation: usually suggest
 > 1/3 no symptom at
presentation
Zone 1 injury
 Esophageal evaluation endoscopy ,
contrast esophagogram
 Contrast medium
 Barium- based
 Gastrografin ( meglumine diatrizoate)
 Combination tests should not miss an njury
 CT scan
 Determine the path of projectile
Zone 2 injury
 Largest zone,most common site of




trauma 60-75%
Between angle of mandible & inf border
of cricoid cartilage
Isolate venous injury &
pharyngoesophageal injury most
common structure missed clinically
All pt. are admitted for observation and
24 hr re-evaluation
50% of death  hemorrhage from
vascular structure
Zone 2 injury
 Symptomatic  neck exploration
 Asymptomatic
 Directed evaluation and serial exam
 Arteriography,
 Laryngotraheoscopy
 flexible esophagoscopy
 barium swallow
 Requires adequate physician ,24 hr facility prepared for
emergency testing and Surgery
Zone 3 injury
 Superior to angle mandible to skull base
 Potential for injury to major blood vessel and CN
near skull base
 Arterial injury
 may be asymptomatic at presentation
 Surgical exposure and control bleeding may be
difficult
 amenable to definitive treatment by an interventional
radiologist
 Vertebral artery injury appear to be relatively rare
 Should be imaged if bullet path is near the vertebral
column
 Four vessel angiography
Angiography
: Zone1 & 3
 Routine preoperative arteriography in stable case
 Surgical approach is more difficult than zone 2
 If wound involve both side of neck ( stable but
symptomatic) four vessel angiography
Angiography
: Zone1 & 3
Angiography
: Zone2
 Easy accessible,low risk for exploration
 Certain indication for an angiogram in zone 2
 Stable pt. who has persistent hemorrhage
 Neurodeficit compatible with adjacent vascular structure damage eg.
Horner’s syndrome , hoarseness
 Need exploration
 Positive arteriography
 Negative arteriography but positive clinical sign
 Asymptomatic in zone 2
 Controversy,
 No sig difference btw. Clinical exam & angiography
 CTA fast ,minimal invasive in hemostatic stable
Management of vascular injury
zone 1
 Vascular perforation 
requires thoracic Sx
 Mediastinotomy extension
or formal lateral
thoracotomy
Management of vascular injury
zone 3
 Injury at the skull base can
be temporalize by pressure
 Mandibulectomy in
midline
 Temporaly arteral bypass of
carotid artery
Management of vascular injury
 All vein in the neck can be
safely ligated to control
hemorrhage
 injury both internal jugular
vein  try repair
 All external carotid artery
suture ligation
 Good collateral circulation
Management of vascular injury
 Common carotid
artery/internal carotid artery
in zone 2
 Approach along SCM
 if no pulsating followed
retrograde from facial
artery/sup thyroid artery
Technique of vascular repair
 End to end or autogenous graft
reccomended when stenosis is evident
by arteriography
 Ligation of common or internal carotid
a.reserved for irreparable injury and in
pt, who are in a profound coma state
 Delayed complication from unrepaired
vascular injury
 Aneurysm formation
 Dissecting aneurysm
 AV fistulas
Technique of vascular repair
 Intervention radiologists used angiography technique to treat
vascular injury
 Embolization
 Zone 3  high incidence of multiple vascular injury event
 Complication of intervention angiography
 Blood vessel injury
 Inadvertent balloon detachment
 Ischemic events
 Pseudoaneurysm formation
 Treatment failure
Pharynx and esophageal injury
 Clinical sign and symptom  neck exploration
 subcutaneous emphysema
 Hematemesis
 Hypopharyngeal blood
 >50%of Pt.  asymptomatic at presentation
 Combination of esophagoscopy and contrast esophagography
 Most sensitive for detected injury
 Delayed explore & repair beyond 24 hrs after injury
poorer outcome
Digestive tract evaluation
 Possible esophageal perforation 
gastrografin swallow
 Barium : extravasation & distort soft
tissue plane and toxic
Digestive tract evaluation
 Flexible esophagoscopy
 Missed perforation : cricopharyngeus,
hypopharynx
 Negative endoscopy but air leak in
soft tissue  mandatory neck explore
 Infiltrate methylene blue : localize
injury size
 Combination of flexible and rigid
endoscopy
 Exam entire cervial and upper
esophagus
 No perforation missed
Digestive tract evaluation
 Suspicious pharyngeal perforation
 NPO for several days
 S&S : fever , tachycardia,widening of
mediastinum
 Repeat endoscopy or neck exploration
 Esophageal injury in the early phase
 Two layer closure with wound irrigation
 Debridement
 Adequate drainage
 Extensive esophageal injury  lateral
cervical esophagostomy
Digestive tract evaluation
 C-spine fx  omitted rigid esophagoscopy
 Clinical exam
 F/U exam frequently
 Monitor V/S
 Observe period 48-72 hrs
Penetrating of hypopharynx
 Superior to the level of arytenoid cartilage
 IV ABO
 NPO ทางปาก 5-7 days
 Primary closure not always necessary
 Inferior to the level of arytenoid cartilage
 Dependent portion
 Exploration with primary watertight closure
 Use absorbable suture with drainage of adjacent
neck space
 NPO 5-7 days
 Treat liked esophageal injury
Treatment
 Conservative
 Medical therapy
 Adequate ventilation & oxygenation
 Fluid resuscitation
 Monitor neurolodic status
 Pain control
 ABO
 Tetanus prophylaxis
Treatment
 Surgical approach
 Zone 1
 Median sternotomy
 Thoracotomy
 Zone 2
 Collar incision
 Apron incision
 Zone 3
 Consult neuroSx
Blunt neck trauma
 motor vehicle accidents and sports
 result in laryngeal, vascular, and digestive injury
 easily underdiagnosed because their onset can be delayed
 occult cervical spine injury
Blunt neck trauma
 careful observation : delayed onset
 slow progression of airway edema
 airway obstruction may not occur until several hours after the injur
 CT may be helpful to determine degrees of injury to the
larynx and vessels
Blunt neck trauma
 Blunt injury to the cervical vessels can lead to
 thrombosis, intimal tears, dissection, and pseudoaneurysm
 Treatment options for blunt artery injuries are based on
the mechanism, type of injury, and location
Blunt neck trauma
Treatments for blunt artery injuries include
surgery, anticoagulation, and observation.
Surgical intervention for blunt vascular injuries includes ligation,
resection, thrombectomy, and stent placement