Blunt and penetrating neck injury

referenceB.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

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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 IFrom 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 IIFrom cricoid to angle of mandibleTracheaLarynxCarotid and vertebral aa.Jugular VeinEsophagusSpinal Cord

Zone IIIAngle of mandible to base of skull

Distal carotid and vertebral arteriesPharynx Spinal cord

PENETRATING NECK TRAUMAPresently, 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 objectshandgunRifleShotgunsKnife and stab injuries

Physical properties of penetrating objectsKinetic energy= ½ mv2

m = massV = velocity

Degree of woundFirearm

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 objectsGunshot wound

tissue injury from 2 mechanismDirect tissue injuryTemporary

caviationLow velocity

tissue damageHigh velocity

tissue loss

KNIFE and STABKnife, ice-pick, cut-glass, or razor-blade more predictable pathwayssingle-entry wound may be from multiple stab

woundscervical 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 principleA : airway with C-spine controlB : breathing and ventilationC : circulationD : disability and neurologic statusE : exposure and evaluation other injury

A : AirwayMost casecarefully

intubated transorallyIf 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 : AirwayMultiple 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 : AirwayObvious tracheal

injury carefully intubated through entry wound using armored/reinforced ETT

B: BreathingAdminister high-flow

oxygenMonitor : pulse oximetryDifficulty ventilation

may upper airway or thoracic injury

Unequal breath sounds & asymmetric chest movement inadequate ventilationPneumothoraxHemothoraxTension pneumothorax

C : CirculationControl active bleeding

with direct pressureDo not clamp bleeding

vesselsSubsequent 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 : DisabilityNeurodeficit 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])

SYMPTOMAirway

Reparatory distress

Stridor HemoptysisHoarsenessTracheal deviationSubcutaneous

emphysemaSucking wound

Vascular System HematomaPersistent bleeding  Neurologic deficitAbsent pulseHypovolemic shock BruitThrill 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

SYMPTOMNervous 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 ExplorationImmediately 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 injuryBelow cricoid,

dangerous areaProtect zone bony

thorax and clavicleMotality 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 injuryEsophageal evaluation

endoscopy , contrast esophagogramContrast medium

Barium- basedGastrografin ( meglumine

diatrizoate)Combination tests should not

miss an njuryCT scan

Determine the path of projectile

Zone 2 injuryLargest zone,most common site

of trauma 60-75%Between angle of mandible & inf

border of cricoid cartilageIsolate 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 injurySymptomatic neck explorationAsymptomatic

Directed evaluation and serial examArteriography,Laryngotraheoscopyflexible esophagoscopybarium swallowRequires adequate physician ,24 hr facility

prepared for emergency testing and Surgery

Zone 3 injurySuperior to angle mandible to skull basePotential for injury to major blood vessel and

CN near skull baseArterial injury

may be asymptomatic at presentationSurgical exposure and control bleeding may be

difficultamenable to definitive treatment by an

interventional radiologistVertebral artery injury appear to be relatively

rare Should be imaged if bullet path is near the

vertebral column Four vessel angiography

Angiography: Zone1 & 3Routine preoperative arteriography in

stable caseSurgical approach is more difficult than

zone 2If wound involve both side of neck ( stable

but symptomatic) four vessel angiography

Angiography: Zone1 & 3

Angiography: Zone2Easy accessible,low risk for explorationCertain indication for an angiogram in zone 2

Stable pt. who has persistent hemorrhageNeurodeficit compatible with adjacent vascular

structure damage eg. Horner’s syndrome , hoarseness

Need explorationPositive arteriographyNegative arteriography but positive clinical sign

Asymptomatic in zone 2 Controversy,

No sig difference btw. Clinical exam & angiographyCTA fast ,minimal invasive in hemostatic stable

Management of vascular injuryzone 1Vascular

perforation requires thoracic Sx Mediastinotomy

extension or formal lateral thoracotomy

Management of vascular injuryzone 3Injury at the skull

base can be temporalize by pressureMandibulectomy in

midlineTemporaly arteral

bypass of carotid artery

Management of vascular injuryAll vein in the neck

can be safely ligated to control hemorrhage

injury both internal jugular vein try repair

All external carotid artery suture ligationGood collateral

circulation

Management of vascular injuryCommon carotid

artery/internal carotid artery in zone 2 Approach along SCMif no pulsating

followed retrograde from facial artery/sup thyroid artery

Technique of vascular repairEnd 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 formationDissecting aneurysmAV fistulas

Technique of vascular repairIntervention radiologists used angiography

technique to treat vascular injury Embolization Zone 3 high incidence of multiple vascular

injury eventComplication of intervention angiography

Blood vessel injuryInadvertent balloon detachmentIschemic eventsPseudoaneurysm formationTreatment failure

Pharynx and esophageal injuryClinical sign and symptom neck exploration

subcutaneous emphysemaHematemesisHypopharyngeal blood

>50%of Pt. asymptomatic at presentationCombination of esophagoscopy and contrast

esophagographyMost sensitive for detected injury

Delayed explore & repair beyond 24 hrs after injury poorer outcome

Digestive tract evaluationPossible esophageal

perforation gastrografin swallow

Barium : extravasation & distort soft tissue plane and toxic

Digestive tract evaluationFlexible 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 endoscopyExam entire cervial and

upper esophagusNo perforation missed

Digestive tract evaluationSuspicious pharyngeal perforation

NPO for several daysS&S : fever , tachycardia,widening of

mediastinumRepeat endoscopy or neck exploration

Esophageal injury in the early phaseTwo layer closure with wound irrigationDebridementAdequate drainage

Extensive esophageal injury lateral cervical esophagostomy

Digestive tract evaluationC-spine fx omitted rigid esophagoscopyClinical exam

F/U exam frequentlyMonitor V/SObserve period 48-72 hrs

Penetrating of hypopharynxSuperior to the level of arytenoid

cartilageIV ABONPO ทางปาก 5-7 daysPrimary closure not always necessary

Inferior to the level of arytenoid cartilageDependent portionExploration with primary watertight

closureUse absorbable suture with drainage of

adjacent neck spaceNPO 5-7 daysTreat liked esophageal injury

TreatmentConservative

Medical therapyAdequate ventilation & oxygenationFluid resuscitationMonitor neurolodic statusPain controlABOTetanus prophylaxis

TreatmentSurgical approach

Zone 1Median sternotomyThoracotomy

Zone 2Collar incisionApron incision

Zone 3Consult neuroSx

Blunt neck traumamotor vehicle accidents and sports result in laryngeal, vascular, and digestive

injuryeasily underdiagnosed because their onset

can be delayedoccult cervical spine injury

Blunt neck traumacareful 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 traumaBlunt injury to the cervical vessels can lead to

thrombosis, intimal tears, dissection, and pseudoaneurysm

Treatment options for blunt artery injuries are based onthe mechanism, type of injury, and location

Blunt neck traumaTreatments for blunt artery injuries include

surgery, anticoagulation, and observation.

Surgical intervention for blunt vascular injuries includes ligation, resection, thrombectomy, and stent placement