Transcript Injuries to the Neck

Penetrating and Blunt Neck Injuries
“Deadly Missed Injuries”
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
Types of Injury - Penetrating
• 40% do not involve important structure
• GSW direct and delayed type of injury
• Structures
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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%
Type of Injury - Blunt
• Cervical spine
• Vascular injuries
– internal carotid artery
– vertebral carotid artery
• Aerodigestive
– esophageal (rare)
– larynx
Deadly Missed Neck Injuries
• Carotid Artery Injury
• Esophageal Perforation
• Laryngotracheal Injury
Diagnosis
• 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 (A J Surg 1987) 3/10 no signs or symptoms
– laryngeal
• more likely to have presenting symptoms/signs
• voice change, SOB, hemoptysis
Keys to Diagnosis
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Little need for labs
High index of suspicion
Sense of urgency
Operation vs radiology
Case #1
• 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
• ??
Penetrating Neck Zones
Vascular Injuries - Physical Exam
• Penetrating
– Fogelman et al (Am J Surg,1956)
• 43% hemodynamically stable
• 70% no sign of bleeding
– Carducci et al(Ann Emerg Med, 1985)
• 1/3 no signs/symptom
– Apffelstaedt et al (World J Surg, 1994)
• Prospective study, 335 patients
• SW penetrating platysma
• clinical signs absent 30% of positive neck
explorations
Physical Exam - Penetrating
• Reliable for significant vascular injuries
– Demetriades et al (Br J Surg, 1993)
• prospecitive 335 patients, detailed written protocol
• 7/335 required angiography
• 269/335 nonoperative managed
– 2 required subsequent operations for vascular injury
– no complications
– Demetriades et al (World J Surg, 1996)
• prospective 223 patients, strict written protocol(Doppler)
• 160/223 no clinical signs underwent angio
– no vascular injury requiring treatment
Overview Management Penetrating Neck
• Zone I
– routine angiography
– ? Esophageal evaluation (EGD, swallow)
– Airway evaluation (bronchoscopy)
• Zone II
– selective management vs operative
– neither approach superior (Asensio et al, Surg Clin N Amer, 1991)
• Zone III
– routine angiography
Angiography
• Recommended in Zone I and III
– difficult to assess clinically
– difficulty surgical exploration
• Policy reduces nontherapeutic intervention
• Costs (Demetriades et al, Br J Surg, 1993)
– Zone I only 5% required operation
– Zone III only 13% required operation
Zone III GSW
Zone III GSW
Management Penetrating Zone II
• 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
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
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%
Zone II - “Selective Conservatism”
• If hemodynamically stable
– angiography, contrast study, endoscopy , +/laryngoscopy
• Exploration if positive study
• Negative neck exploration 20%
• Missed injuries negligible (Jurkovich et al, Trauma, 1985)
• Disadvantages
– cost and time
– iatrogenic (CVA, esophageal perfs)
Acute Management Zone II Injury
Treatment- Specific 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
Treatment- Specific Injuries
• Carotid injury
– Presence of neurologic deficits
• controversial
• ? Concern of postvascularization hemorrhagic infarct
• increased risk if evidence of sever anemic infarct or
edema
• recommend repair
– if deficits are short of coma
– no evidence of anemic infarct
– patent distal carotid
Treatment- Specific Injuries
• Carotid artery occlusion with symptoms
– may result in late local or neurologic complications
– may develop pseudoaneurysm or rupture
– recommend repair if
• technically feasible
• not at base of skull
Carotid Intimal Flap
Treatment - Specific Injuries
• 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 - Specific Injuries
• Vertebral artery
– increased frequency secondary liberal angio
– 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
• 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
Case #2
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56 yom s/p MVC driver vs pole
Found unconscious at scene, intubated
VS: HR 90, BP 110/80, sat 100%
PE:
– abrasions to left shoulder/mid chest/LUQ
– GCS 7, pupil equal/reactive
• ??
Carotid Artery Dissection
Internal Carotid Occlusion
Blunt Carotid Injury
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Low incidence (0.08-0.25%)
Male 76%, Mean age 35 +/- 2 yrs
Most commonly intimal disruption
? asymptomatic
– Louisville U. (1998) 24 BCI all symptomatic
– Colorado U. (1998) 12/56 asymptomatic
• Often delayed diagnosis (Krajewski, Ann Surg 1980)
– 58% > 10hrs
– 36% > 24 hrs
Blunt Carotid Injury
• Eiology
– MVC 41% (seat belt not
a factor)
– Fall/ped struck 14%
– MCC 11%
– other 22%
• ski
• bike
• assault
• near hanging
• horseback
• Associated injuries
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CHI 65%
facial fx 60%
thoracic 51%
basilar skull fx 32%
extremity fx 32%
abdominal 30%
pelvic fx 16%
cervical fx 5%
none 16%
Biffl et al, Ann Surg, 1998
Diagnosis - Vascular Injury
• Careful PE
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hematomas, bruit, thrill
Horner’s syndrome
limb paresis or paralysis
deep coma
• Delayed up to several days
• PITFALL: Failure to consider blunt carotid
injury with negative CT and CNS changes
delayed
Blunt Carotid Injury
• Screening asymptomatic (Biffl et al, 1998)
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severe neck hyperflexion, flexion, or rotation
significant soft-tissue injury anterior neck
cervical spine fracture
displaced midface fx or mandibular fx associated
with a major injury mechanism
– basilar skull fx involving
sphenoid/mastoid/petrous/foramen lacerum
Blunt Carotid Injury
• Biffl et al, 1998 (continued)
– before screening 12/12429 (0.1%)
– after screening 25/2902 (0.86%)
• only 28% had lateralizing signs/symptoms
• 25% had concomitant head injury/depressed MS
– symptoms and timing
• > 24 hrs - 28%
• > 1 week - 8.3 %
Blunt Carotid Injury
• Biffl et al, 1998 (continued)
– Outcome by symptoms at diagnosis
Dead
Asymptomatic
1
Symptomatic
7
Major Minor Normal
1
0
11
6
5
6
Blunt Carotid Injury
• Biffl et al, 1998
– Treatment
• Operative =1/37
• Anticoagulation = 24/37
– endovascular stent 10/24
• No intervention = 11/37
– Outcome
Dead
Anticoagulation
1
No Anticoagulation
3
Major Minor Normal
6
4
13
1
1
4
Blunt Carotid Injury
• Biffl et al, 1998
– Complications
• angiography (2) - groin hematoma(1), CVA (1)
• hemorrhagic
– 54% rebleeding ( transfusions and/or cessation)
– Summary
• Anticoagulation improves outcome
– confirmed Fabian et al, Ann Surg, 1996
• Aggressive screening ( ? Diagnostic test)
• Optimal intervention ?
• Stenting pseudoaneurysm
Blunt Carotid Injury
Contraindicaton to Heparin
No
Heparin
Yes
Observe
Angiography 7-10 d
Pseudoaneurysm
No
Coumadin 3 mos
Yes
Heparin/Stent or OR
Vascular Injury - Radiologic Test
• C- spine films
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r/o fractures (spine/larynx)
? subcutaneous air
anterior cervical soft tissue swelling
tracheal deviation
• ? CXR/ skull xray (where’s the bullet ?)
BCI and Anticoagulation
Fabien et al, Surg, 1996
Vascular Injury - Radiologic Test
• Duplex
– can be used for carotid injuries Zone II only
– as useful as angio in stable patients with Zone II injury
(Thal, Trauma, 1991)
• operator dependent
• CT Angiogram
– limited studies
– ? comparable to angiogram (missed blunt injuries)
– advantage: no risk of CVA
Vascular Injury - Radiologic Test
• Angiography
– gold standard (4 vessel runoff)
– Indications
• proximity to carotid with or without hematoma
• shotgun blasts with ? multiple artery segments injuries
• precise localization for planning proximal or high
carotid injury
• blunt trauma with extensive soft-tissue injury
• blunt trauma with neurologic loss unexplained by CT
Case #3
• 29 yof restrained driver, head-on MVC
• reported striking face/neck on steering wheel
c/o neck/throat pain
• airway patent without voice change
• PE:
– anterior neck crepitus
– no stridor
• ??
Diagnosis - Esophageal
• 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
• Rec: If gastrograffin study is negative, repeat
swallow this barium. Avoid gastrograffin in
patients without gag/cough
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%
Treatment - Esophageal Injury
• Negative studies/high suspicion
– 24 hr observation
• Pharyngeal
– usually non-operative
– NPO/IV Abx
• Esophageal
– resection
– ? diversion
Laryngotracheal Injury
• Larynx extends from epiglottis opposite C3 to
cricoid cartilages at level C6
• Cervical trachea cricoid to thoracic inlet
• Injury
– penetrating
– blunt
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
Blunt Laryngotracheal Injury
• Most common cause is MVC
– hitting steering wheel or dashboard
– “clothesline” with ATV/snowmobile
• Endotracheal intubation
– arytenoid subluxtion
– recurrent nerve paralysis (balloon overinflation)
Thyroid Fracture
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