Transcript Injuries to the Neck

Penetrating Neck Injuries:
Mandatory Exploration vs. Nonoperative
Management
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
Debate Continues………
“ Some authors have advocated mandatory exploration
of all penetrating neck wounds on the basis that
serious injury can exist in the absence of clinical
findings. Others have advocated a selective approach,
operating only upon patients whose finds suggest a
major vascular or visceral injury.”
A.J. Roon and N. Christensen, Evaluation and Treatment of
Penetrating Cervical Injuries, J Trauma, 1979, 19:391
Overview – Penetrating Neck Injuries
• Management based on “Neck Zones”
– Background
– Rationale for and against
• General clinical diagnosis
• Specific injuries – Diagnosis and Management
– Carotid
• Zone II – Mandatory Exploration vs. Selective Nonoperative
– Vertebral
– Esophagus
– Larynx
History of Neck Zones
A.J. Roon and N. Christensen, Evaluation and Treatment of
Penetrating Cervical Injuries, J Trauma, 1979
• Retrospective study
– 189 patients from 1970 -1977
– GSW = 49, SW = 140
• Treatment options
– Based on location of neck wound
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Neck zones
– Considered level of entrance wound important part of
preoperative evaluation
– Based on involved vascular structures where distal or
proximal control viewed as difficult
– Obtained arteriography on all patients with high or low
neck wounds
• Vascular injury may not obvious
• Plan appropriate operative approach to minimize
bleeding
Penetrating Neck Zones
Zone III
Zone II
Zone I
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979, 19:391
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Clinical findings
– 74 % had one or more signs of vascular, UGI or
airway injury
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hemorrhage (50%)
hematoma (34%)
shock (15%)
neurologic signs (12%)
– 26 % no signs (only 6 % had positive explorations)
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Location of wounds
– Middle zone (98 pts)
– Low or high zone (91 pts)
• Treatments
– Middle zone – immediate exploration
– Low or high zone – angiogram if stable (62 pts)
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negative = 47
positive = 14
false positive = 1
false negative = 0
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Results
– 35 patients not explored
– 154 patients explored
• 47% positive findings
– GSW 59%
– SW 43%
– 123 repairs performed
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Venous – 46
Arterial – 36
Airway – 26
Esophageal – 3
Miscellaneous - 11
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Mortality (2.6 %)
– Positive explorations = 2.6 %
– Observation = 0%
– Negative exploration = 0%
• Morbidity (5.3%)
– Observation = 0 %
– Negative exploration = 4 %
– Positive exploration = 7 %
A.J. Roon and N. Christensen, Evaluation and Treatment
of Penetrating Cervical Injuries, J Trauma, 1979
• Conclusions
– All patients with wounds penetrating the platysma should have a neck
exploration
– Patients with high or low wounds should have preoperative arteriograms
if they are stable
• Time to exploration
– no arteriogram = 2.4 hrs
– arteriogram = 4.8 hrs
• Angiogram changed approach ( 6 %)
– Repair all vascular injuries, unless carotid occluded
– Lower mortality with mandatory exploration (?)
• Observation = 0 % (required more radiological studies, time, effort, cost)
• 2.6 % compared to reported 10-30% with selective observation
Neck Zone Concept Outdated ?
• Location of skin wound not a reliable indictor of
underlying injuries
• Length of neck makes it impractical to divide into
three short zones
• Wounds often occur at border between zones and
difficult to classify
Epidemiology of Penetrating Neck Injuries
• 40% do not involve important structures
• Types
– GSW 50% (direct and indirect damage)
– SW 45%
– Shotgun 5%
• Structures involved
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major vein 15-25%
major artery 10-15%
pharynx or esophagus 5-15%
larynx or trachea 4-12%
major nerves 3-8%
Stab vs. Gunshot Wounds
• Anecdotal suggestion
– explore GSW, non-operative SW
– not supported in literature
• Prospective study (Demetriades et al, Br J Surg, 1993)
– 97 GSW, 89 SW
– GSW higher incidence of clinical signs than knives
(35% vs. 19%)
– GSW more likely injuries
– therapeutic operation: GSW 16.5%, SW 10.1%
Clinical Diagnosis – Neck Injuries
• Significant injuries often asymptomatic
– 25% positive symptoms and 25% positive signs
– PE is often deceptively negative for severe injury
• Symptoms variable and delayed
– internal carotid artery > 2 weeks
– esophageal
• Weigelt et al, Am J Surg, 1987; 154:619
– 3/10 no signs or symptoms
– laryngeal
• more likely to have presenting symptoms/signs
• voice change, SOB, hemoptysis
Case #1
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21 yom with GSW to right neck without exit site
c/o pain in throat/right neck
VS : HR 110, BP 130/70, RR 27 sats 98% (40%)
PE:
– mild swelling right neck, non-pulsetile
• Management options ?
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observation (physical exam based)
selective approach
diagnostic approach
mandatory exploration
Clinical Signs – Vascular Injury
• “Hard”
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Active or pulsetile bleeding
Expanding hematoma
Bruit or thrill
Neurologic deficit
(unilateral)
– Deficit pulse exam
– Hypotension
• “Soft”
– Nonexpanding hematoma
– Paresthesias
Physical Exam – Missed Injuries
• Fogelman MJ and Stewart RD , Am J Surg,1956, 91:581
• 100 consecutive patients
• 43% hemodynamically stable
• 70% no sign of bleeding
• Carducci et al, Ann Emerg Med, 1985, 15:208
• 1/3 of patients without signs/symptoms
• Apffelstaedt et al, World J Surg, 1994, 18:917
• Prospective study, 335 patients
• SW penetrating platysma
• clinical signs absent 30% of positive neck explorations
Physical Exam - Reliable Diagnosis
• Demetriades et al, Br J Surg, 1993
– Prospective, 335 patients, detailed written protocol
– 7/335 required angiography
– 269/335 non - operatively managed
• 2 required subsequent operations for vascular injury
• no complications
• Demetriades et al, World J Surg, 1996, 21:41
– Prospective, 223 patients, strict written protocol
– 160/223 - no clinical signs underwent angiogram
• no vascular injury requiring treatment (NPV 100%)
Physical Exam – Reliable Diagnosis
• Biffl et al, Am J Surg, 1997, 174:678
– Prospective, 312 patients with penetrating neck injuries
• Immediate OR = 105 (symptomatic)
– 16 % non-therapeutic
• Observation only = 207 (asymptomatic)
– 1 delayed operation for esophageal perforation
• Sekharan et al, J Vasc Surg, 2000, 32:483
– Prospective, 145 Zone II injuries
• Immediate OR = 31 patients (hard signs)
– 90% with major arterial/venous injury requiring repair
• Observation = 91 patients
• Arteriography = 23 patients
– 1 required operative repair of common carotid artery
Penetrating Neck Trauma - Radiographic Options
• Arteriography
– “gold standard”
– no or minimal complications
• Controversial
– Duplex scan
– CT angiogram
Angiography
• Recommended in Zone I and III
– difficult to assess clinically
– difficulty surgical exploration
• Policy reduces non-therapeutic intervention
• Costs (Demetriades et al, Br J Surg, 1993)
– Zone I only 5% required operation
– Zone III only 13% required operation
Angiography - Zone III GSW
Zone I Injuries - Angiography
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Eddy, et al, J Trauma, 2000, 48:208
? Mandatory angiography in all Zone I injuries
Retrospective over 10 years, 138 patients
Arteriography vs. Physical exam/CXR
Results
– 28 arterial injuries identified
– 36 patients had normal PE and CXR
– No arterial injuries identified in PE/CXR group
Penetrating Neck Injuries - Duplex
• Demetriades et al, Arch Surg, 1995, 130:971
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Prospective, 82 stable patients with neck wounds
Angiography and color flow doppler imaging
Zones: I - 30%, II - 53%, III - 31%
Angiography
• Identified 11 lesions, 2 required repair
– Doppler
• Identified 10 lesions, missed intimal tear in CCA
• 91% sensitive, 99 % specific
• 100% for clinically important lesions
Penetrating Neck Injuries - Duplex
• Ginzberg et al, Arch Surg, 1996, 131:691
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Prospective, 55 stable penetrating neck wounds
Duplex ultrasonography in all patients
Compared results with arteriography or OR findings
Results
• Duplex
– Normal - 76%
– Abnormal – 24% ( 11 truly abnormal, 2 false positive)
– Outcomes
• NPV 100%
• PPV 85%
Penetrating Neck Injuries – CT Angiogram
• Gracias et al, Arch Surg, 2001, 136:1231
– Retrospective, 23 stable patients with neck injuries
– Helical CT angiogram for trajectory determination
– Results
• 13/23 had trajectories remote to vital structures
– No further intervention
– 10/23 underwent angiogram (3 required embolization)
• Outcomes
– No adverse outcome
– Prolonged time to angiogram via CT (added 1.5 hrs)
– 4 discharge from ED
Zone II Injuries – CT Angiogram
• Mazolewski et al, J Trauma, 2001, 136:1231
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Prospective, 14 stable Zone II injuries
Helical CT angiogram then exploration
Surgeons predicted 4/14 significant injuries by CT scan
Results
• 3/14 patients with significant injuries
• Correlated with CT findings
– Outcomes
• Sensitivity 100%, NPV 100%
Management - Mandatory Exploration
• Mandatory exploration
– Advantages
• decreased injuries
– up to 25% unexpected injuries found
• low morbidity/mortality
– Disadvantages
• report up 67% negative exploration
– Recommendations
• Zone II injuries with/without instability
• GSW that cross midline
Supportive – Mandatory Exploration
• Meyer et al, Arch Surg, 1987, 122:592
– Prospectively studies 120 Zone II injuries
• Emergent OR = 7
• Diagnostic evaluation followed by neck exploration = 113
– Arteriography
– Barium swallow and flexible esophagoscopy
– Laryngoscopy
– Outcome accuracy
• Clinical assessment = 86 %
• Diagnostic assessment = 94 %
• Operative assessment = 100 %
– Complications = 6%, Mortality = 0.8%
Management - Selective Approach
• If hemodynamically stable
– angiography, contrast study, endoscopy , laryngoscopy
• Exploration if positive study
• Negative neck exploration 20%
• Disadvantages
– cost and time
– iatrogenic (CVA, esophageal perforations)
Supportive – Selective Approach
• Jurkovich et al, Trauma, 1985, 25:819
– Missed injuries negligible
• Sofianos et al, Surgery, 1996, 120:785
– Prospectively studied 75 Zone II injuries
• Immediate operation = 40 (hard signs present)
• Selective approach = 35
– Only 11 had either arteriography, contrast swallow, or endoscopy
– No incidence of missed injury, morbidity, or mortality
Transcervical GSW
• More likely to involve vital structures
– 73% vs. 31% (GSW not cross midline)
• Hirshberg et al, Am J Surg 1994
– retrospective 41 patients
– 30(83%) positive for cervical injury
– recommends mandatory exploration
• Demetriades et al, J of Trauma, 1997
– prospective, 33 patients
– 73% injury to vital organ, only 21% therapeutic operation
Treatment Options – Carotid Artery Injuries
• Carotid injuries
– 22% of penetrating cervical vascular injuries
– mortality 10-20% (in-hospital)
– Repair vs. ligation
• repair if possible in absence of neurologic deficits
• prefer saphenous vein, but prosthetics ok
• if internal carotid injuries, transposition of external
carotid
• ligation in neurologically intact for high internal carotid
injury if very difficult or impossible
Carotid Artery Injury Management
Carotid Artery Injury
Common or External Carotid
Internal Cartoid
Simple or Complex
in Stable Patient
Complex Injury in
Unstable Patient
Minimal or No
Back Bleeding
Repair
Ligate
Ligate
Good Back Bleeding
Stable
Unstable
Repair
Ligate
Carotid Artery Interposition Repair
Carotid Artery Transposition Repair
ICA Stump
Treatment Options – Neurologic Deficits
• Presence of neurologic deficits
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controversial
? concern of post-vascularization hemorrhagic infarct
increased risk if evidence of severe anemic infarct or edema
recommend repair
• if deficits are short of coma
• no evidence of anemic infarct
• patent distal carotid
Carotid Intimal Flap
Treatment – Intimal Flaps
• Minor carotid injuries (intimal flaps)
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natural history not known
controversial: observation vs. aggressive approach
? role of duplex for decision making
role of anti-platelet unproven, but used
Vertebral Artery Pseudoaneurysm
Management – Vertebral Artery Injuries
• Vertebral artery
– increased frequency secondary liberal angiography
– 10% of major vascular injuries
– 67% have association with major cervical injury mainly
spine
– isolate injury asymptomatic in 1/3 patients
– thrombosis rarely lead to neurologic sequelae
– angiographic embolization standard of care if bleeding
Complications – Vertebral Artery Injuries
• Nonoperative Management
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delayed bleeding
CVA (dissection, emboli)
pseudoaneurysm
sepsis (missed esophageal leak)
• Operative Management
– injury to nerves (vagus, hypoglossal, recurrent)
– blood loss
– missed injury (particularly esophageal)
Summary Treatment - Vascular Injury
• Surgical exploration unstable and stable Zone II
(board answer)
• Angiography Zone I and III
• ? Nonoperative management stable Zone II
– depends on expertise and facilities
• Other interventions
– embolization high carotid or vertebral artery
– endovascular stent (pseudoaneurysms)
– anticoagulation blunt carotid/vertebral artery
Diagnosis – Esophageal Injuries
• Blunt esophageal injury rare
• High index of suspicion in blunt trauma
• Penetrating trauma
– evaluation part of a complete work-up
• If missed, high morbidity/mortality
GSW Anterior-Posterior Neck
Esophageal Injury - Diagnostic Test
• Contrast swallow
– Extravasation is diagnostic
– Negative study is not reliable (particular in neck with
gastrograffin)
– 50% of leaks missed with gastrograffin
– 25% of leaks missed with barium
Gastrograffin swallow
Esophageal Injury - Diagnostic Tests
• Controversy of initial contrast to use
– gastrograffin
• pneumonitis if aspirated
– barium
• increased inflammation/infection in the mediastium
• Recommendation: If gastrograffin study is negative,
repeat swallow this barium. Avoid gastrograffin in
patients without gag/cough or unprotected airway
Esophageal Injury - Diagnostic Test
• Endoscopy
– Generally recommended when contrast swallow is
negative, but suspicion is high
– Perforations often readily seen, however
• 50% missed (Weigelt et al Am J Surg 1987)
• missed in pharynx and cervical esophagus
• missed in patients on ventilator (poor expansion of
esophagus)
• Combination of swallow/esophagoscopy reduces
missed injuries to < 5%
Esophageal Injury - Delay in Diagnosis
• AAST Multicenter Study – Penetrating Esophageal Injury
• Arsensio, et al, J Trauma, 2001, 50:289
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34 US centers over 10 years
Retrospective 346 patients
Two groups: immediate OR vs. diagnostic testing
Results
• Time to OR: preop evaluation -13 hrs., no preop - 1 hr.
• Complications
– Overall: preop – 134, no preop – 87 (p < 0.001)
– Esophageal related: preop – 74, no preop – 32 (p< 0.003)
• Overall Mortality – 19%,
– Outcomes independent risk factors
• Time delays in preop evaluation, OIS > 2, and resection/diversion
Treatment - Esophageal Injury
• Negative studies/high suspicion
– 24 hr observation
• Pharyngeal
– usually non-operative
– NPO/IV Abx
• Esophageal
– resection
– ? diversion
Primary vs. Exclusion-Diversion
• Virtually all injuries can be repaired primarily
• Management dictated
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Site of injury
Associated injuries
Condition of patient
Timing of repair ( < or > 24 hrs.)
• Surgical Options
– Primary with reinforcement of flap/patch
– Exclusion-diversion
Exclusion/Diversion
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Usually > 24 hrs post injury
Sepsis and extensive inflammation
Primary goal – DRAINAGE
Approach based on injury location
– Cervical
• Small – often simple drainage
• Large – spit fistula
– Thoracic
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Extensive debridement, drainage
Repair with a Grillo flap (pleura)
Exclusion/diversion +/- continuity (Urschel repair)
T-tube drainage (large defects or contamination
Esophagectomy (rare)
Esophageal Injuries
• Additional considerations
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Antibiotics (cover oral flora)
NGT (5-7 days)
GT and JT placement
? Thoracic duct injury
Penetrating Laryngotracheal Trauma
• 5-15% of penetrating neck trauma
– larynx 33%
– cervical trachea 67%
• Doubled if esophagus injury
• 25% of airway injuries have esophageal injury
Diagnosis - Laryngotracheal Injury
• Pathology
– subglottic/supraglottic submucosa edema/air
– usually occurs within 6 hours
– > 70% cross-sectional area reduced before
symptoms
• Associated with cervical spine injury
• Voice change most common
• Other S/S: dyspnea, pain, score throat, dysphagia,
odynophagia, hemoptysis, subcutaneous air
Diagnosis - Laryngotracheal Injury
• Plain xrays
– soft tissue emphysema
– airway compression
– fracture of laryngeal cartilages
• CT scan
– detailed and accurate appraisal
• Endoscopy
– Flexible vs rigid
– Bronchoscopy/laryngoscopy 100% accurate
Management of Laryngotracheal Injury
• Airway control
• Preparation for surgical airway
• Non-operatively if,
– clinically stable airway
– endoscopy shows no displaced cartilages, mucosal
disruptions or progressive edema/hematoma
– therapy
• semi-fowler position, humidified air, steroids, IV abx
Management of Laryngotracheal Injury
• Operative
– tracheostomy if airway unstable
– no advantage in delay > 24 hrs to repair fx
– laryngeal fractures
• thyroid fx most common
• reduction and fixation with stainless +steel sutures
• delay of reduction > 7-10, scarring makes it more
difficult and return of normal function unlikely
Outcomes of Laryngotracheal Injury
• 1/3 of patients who survive airway injury reach hospital
alive suffer delay in diagnosis and treatment
• preventable death in 10% in upper airway trauma (most
secondary to delay)
• most have some permanent voice and airway impairment
or tendency to aspirate
• problems most significant after blunt injury and
penetrating (more extensive damage)
Errors in Management of Laryngeal Trauma
• Assuming airway problem in unconscious patient is only
due to prolapse of the tongue
• Attempting blind intubation in suspected larygneal injury
• Inserting ET tube with force is through vocal cords and
fails to advance
• Use of muscle relaxation in a patient with a possible
cricotracheal separation
• Inadequate assessment of esophageal injury
Mortality/Morbidity of Neck Injuries
• Mortality
– Vietnam era – 4-7 %
– Today - 2-6 %
– Higher if
• missed cervical injuries - > 15 %
• Loss of airway patency – 33 %
• Morbidity
– Respiratory compromise 10 %
• Zone I injuries highest mortality/morbidity
Keys to Diagnosis & Management
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High index of suspicion
Airway management !
Sense of urgency
Operation vs radiology
Overview - Management Penetrating Neck
• Zone I
– Routine angiography vs. CT angiogram
– Esophageal evaluation (contrast swallow +/- EGD)
– Airway evaluation (laryngoscopy or bronchoscopy)
• Zone II
– Diagnostic vs. selective approach
– Mandatory exploration fading
• Zone III
– Routine angiography vs. CT angiogram
Penetrating Neck Injuries Management
Penetrating Neck Wounds
Assess Airway
Hard Signs
Platysma Violation
Rapid Intubation
Operative Intervention
Carotid Evaluation
Arteriography
Esophagogram
CT Angiography
Laryngoscopy
Questions…?