Transcript Neck Trauma

Neck Trauma
 Penetrating trauma
 Blunt trauma
 Near - Hanging &
Strangulation
Penetrating Trauma
Symptoms of injuries to structures
such as the esophagus can be
subtle or delayed in presentation
Pathophysiology
Mechanism of injury
1. Gunshots ( more dangerous )
2. Stabbings
3. Miscellaneous
Organ System Classification
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Vascular ( most common )
Pharyngoesophageal
Laryngotracheal
Others ( cranial nerve, thoracic duct,
brachial plexus, spinal cord….
Vascular
Three pathophysiologic mechanisms
 External hemorrhage
 Extending soft tissue hematoma,
distort or obstruct the airway
 Disruption of cerebral perfusion
( CVA )
Pharyngoesophageal
 Rarely causes any immediate
consequence
 Delayed diagnosis can lead to
serious soft tissue infection,
mediastinitis and sepsis
Laryngotracheal
 Small puncture wound
 Airflow away from respiratory tree
 Obstruction of airway
Wound Location
Classification
 Anterior
(Sternocleidomastoid muscle )
 Posterior
 Anterior
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Zone 1 ( below cricoid cartilage )
Zone 2 ( between the cricoid
cartilage
and mandible
angle )
Zone 3 ( above mandible angle )
Management of Penetrating
Trauma
Stabilization
 Critically injured patient
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Rapidly assessing vital functions and the area
of injury
Performing stabilizing interventions
Initiating a diagnostic workup
Definitive care
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Violates the platysma ( explore at OR )
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 No immediate life threat
* If hemodynamic stability cannot be
achieved, prompt transfer to the
operating room is in order
Airway
 The risk of spinal cord injury is
minimal
 Cervical cord injury in a gunshot
wound victim when intubation has
never been reported
 Preintubation radiography is
significant
Airway
General
 Most difficult management dilemma: awake
patient with impending airway obstruction
 Preoxygenation is important
# Comatous patients & patients in respiratory
distress require immediate intubation
# It is controversial whether a stable patient with
a nonexpanding hematoma requires intubation
in the ED ( close monitor in the ED )
Airway
Method
 Oral & nasal intubation with or without
endoscopic guidance or muscle
relaxants
 Percutaneous transtracheal ventilation
( PTV )
 Surgical airway
Airway
Method
 PVT
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Airway remains unprotected &
uncomfortable in conscious patient
Temporary intervention
Complication and contraindication
1. Significant airway obstruction & penetrated
airway
2. Subcutaneous emphysema, pneumothorax
Airway
Method
 Surgical Airway
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Last resort ( direct injury to the airway is
exception )
cricothyrotomy
Tracheostomy or even intubation via the
wound
Hemorrhage
External hemorrhage
 Direct pressure
 Blindly clamping bleeding vessels is
avoided
 Quick transfer to the operating room
Inter Hemorrhage
 Airway compromised
 Zone 1 injury result in hemothorax
( thoracostomy )
Definitive Management of
Penetrating Trauma
Unstable patient
Immediate transfer to the OR
Stable patient
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General
Mandatory exploration
Selective Approach
Definitive Management
Stable Patient
 General
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Lateral neck film
CXR ( especially in zone 1 injuries )
NG tube should not be inserted
Prophylactic antibiotics
 Mandatory exploration
 Selective Approach
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A selective method reserves operative
intervention for patients with clinical signs
of significant injury
Clinical Findings:Require Surgical
Intervention Using a Selective Approach
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Expanding or pulsatile hematoma
Presence of a bruit
Horner syndrome
Subcutaneous emphysema
Air bubbling through wound
Hemoptysis or blood - tinged saliva
Shock or active bleeding
Absent peripheral pulses
Respiratory distress
Others are observed & undergo various
diagnostic studies
Other Diagnostic Studies
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Bronchoscopy
Esophagography
Esophagoscopy
Angiography
# Patients with Zone 2 wounds who have
no clinical manifestation of vascular
injury are believed to require no
vascular studies
Disposition of Penetrating
Neck Trauma
No indication for surgery ==>
admission for at least 24 hrs
Blunt Trauma
 Rare, compared with
penetrating trauma
 Motor vehicle crash or an
assault
 Off - road vehicles
Classification of injuries
 Larygotracheal
 Pharyngoesophageal
 Vascular : delayed dissection
or thrombosis ( CVA )
Four recognized mechanisms
by which thrombosis can occur
 A direct blow to the neck
 A blow to the head that causes
hyperextension and rotation of the
head and lateral neck flexion
resulting in a stretch injury to the
vessels
 Blunt intraoral trauma
 Basilar skull fracture
Spinal column and spinal
cord injuries are more
prevalent in blunt trauma
Clinical Feature
Physical findings may be lacking , it
is important to elicit symptoms
1.Dysphagia, odynophagia
2.Voice quality
3.Aphonia, muffled voice ( serious
injury )
Management of Blunt
Neck Trauma
Whether the patient
has
laryngotracheal injury?
Definitive Management
General
C - spine X-ray
 CXR
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Additional Studies
Laryngotracheal
 Vascular
 Pharyngoesophageal
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Additional Studies
 Laryngotracheal
Plain radiographs
 CT
 endoscopy ( fiberoptic bronchoscopy )
( Consult chest surgeon or ENT ? )
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 Vascular
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Angiography
Color Flow Doppler ultrasound
 Pharyngoesophageal
Threshold for performing diagnostic studies
should be low
 Esophagram & esophagoscope
( Consult chest surgeon )
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Disposition of Blunt Neck
Trauma
 Laryngeal injuries do not
require immediate repair
 Tracheal injuries should
receive prompt surgical
attention
Near - Hanging &
Strangulation
Classification of Strangulation
 Hanging ( most common )
 Ligature strangulation
 Manual strangulation
 Postural strangulation
Clinical Features
 Superficial & Deep Neck
 Respiratory (delayed mortality)
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Bronchopneumonia
Aspiration pneumonitis
Delayed airway obstruction
ARDS
 Neuro psychiatric
Management
 Spinal cord injury is very rare
 Phenytoin: useful in preventing
ischemic cerebral damage
 Naloxone
 Ca2+ channel blocker
Summary
Structured approach to these
patients, regardless of
mechanism is essential to
optimize outcome & avoid
catastrophe