Transcript Penetrating Neck Injuries

Penetrating Neck Injuries
Penetrating Neck Injuries
• Case 1
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19 year old male in Casuarina
stabbed back of neck with steak knife (8cm)
Zone II injury
haemodynamically stable
Penetrating Neck Injuries
Penetrating Neck Injuries
Penetrating Neck Injuries
• Case 2
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27 year old male
stabbed in anterior triangle
Zone I injury
required resuscitation at scene
fixed dilated pupils on presentation
Penetrating Neck Injuries
Penetrating Neck Injuries
• Epidemiology
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stab wounds or low velocity missiles
young, otherwise healthy and intoxicated
carotid artery involved in 6%
account for 22% of all cervical vascular trauma
Penetrating Neck Injuries
• Classification
– Anterior/Posterior neck triangles
– Zones
• I = Between clavicle and cricoid
• II = cricoid and angle of mandible
• III = angle of mandible to BOS
Penetrating Neck Injuries
• Zone II most common (47%)
• Zone I (18%) and Zone III (19%)
• multiple zones (16%)
Penetrating Neck Injuries
• Injuries
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arterial
venous
neurological
oesophagus
airways
Penetrating Neck Injuries
• Findings: airways
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airways obstruction
haemoptysis
air bubbling through wound
subcutaneous emphysema
hoarseness
painful swallowing
haematemesis
Penetrating Neck Injuries
• Findings: vascular
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haemodynamic instability
haematoma
reduced pulses (CA, STA, RA)
bruit/thrill
Penetrating Neck Injuries
• Findings: neurological
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GCS
focal UMN signs
cranial nerves (VII, IX, X, XI, XII)
cervical spinal cord
Horner’s syndrome
Brachial plexus
Penetrating Neck Injuries
• Management
– ABCD
– surgical exploration for ‘hard’ signs of vascular
injury (shock, active beeding, enlarging
haematoma, bruit/thrill)
– stable patients with Zone I and III injuries:
angiography with selective intervention
Penetrating Neck Injuries
• Zone II Controversies
– Mandatory versus Selective exploration
– Accuracy of physical examination
– investigation
Penetrating Neck Injuries
• Mandatory exploration
– Apffelstaedt et al. World J Surg 1994
• 393 consecutive patients over 20 months
• 30% of (+) neck explorations had absent clinical
signs
• low morbidity/mortality in negative explorations
• investigations have false (-) and false (+) rates
Penetrating Neck Injuries
• Selective exploration
– Demetriades et al. World J Surg 1997
• 223 patients over 20 months, 176 had angiography
• 34(19%) had positive angiography, 8% required
treatment
• 34 patients with soft signs, 8 had (+) angiogram but
only 1 required treatment
• mandatory exploration leads to high rate (30-89%)
of unnecessary operations
Penetrating Neck Injuries
• Physical Examination
– Sekharan et al, J Vasc Surg 2000
• 145 zone II injuries, retrospective chart review
• 31 had hard signs, 90% (+) exploration
• 23 had angiogram due to proximity to major
structures or involving more than 1 zone.
• 91patients were observed without imaging or
surgery with no evidence of subsequent vascular
injury up to 2 weeks.
Penetrating Neck Injuries
• Physical Examination
– accuracy of 99% in diagnosing significant
vascular injuries with a false negative rate
comparable to angiography.
– However most studies are prolonged
retrospective studies with no uniform protocol
– May miss occult lesions such as smooth
narrowings, intimal irregularities and small
psedoaneurysms and AV fistulas
Penetrating Neck Injuries
• Duplex Ultrasound
– Demetriades et al. 99 patients had duplex
• 11 lesions correctly identified (6 VA, 4 CA, 1 SCA)
• 1 missed lesion (CCA/VA small intimal tears)
• sensitivity 91%, specificity 100%, PPV 100% and
NPV 99%.
Penetrating Neck Injuries
• CT
– Mazolewski et al. J Trauma 2001
• 14 stable patients Level 2
• sensitivity 100%, specificity 91%, PPV 75% and
NPV 100%
Penetrating Neck Injuries
• vertebral artery injury
– clinical presentation and outcome related to
associated injuries.
– 72% have no evidence of arterial trauma
– low incidence of brain stem ischaemia with
unilateral VA ligation
Penetrating Neck Injuries
• oesophageal injury
– very low prevalence
– Demetriades et al
• only symptomatic or obtunded patients should
undergo investigations
Penetrating Neck Injuries
• venous injury
– ligation for major cervicomediastinal venous
trauma is generally well tolerated