Neck ( Non Spinal ) Injuries

8/14/2019 Neck ( Non Spinal ) Injuries

1/15

Introduc

tion

This

chapter

aims to

discuss

the

manage

ment of

soft

tissue

neck

injuries.

It is

specifically

directed

away

from the

manage

ment of

the

cervical

spine

and

spinal

injury in

trauma

patients.

We

mainly

refer to

penetrati

ng neck

injuries,

however

the

assessm

ent and

manage


2/15

ment of

any neck

soft

tissue

injury

should

follow a

common

pathway

in our

opinion.

Specific

consider

ation of

skininvolvem

ent in

these

injuries is

also left

to other

texts.

Soft

tissue

injuries

in the

neck are

difficult

to

assess

and

manage.

This

compact,

important

anatomic

al area

contains

a dense

concentr


3/15

ation of

vital

vascular,

aero-

digestive

and

nervous

system

structure

s; many

of which

are not

accessibl

e to

physicalexaminat

ion and

surgical

exposure

is a

challeng

e. There

has been

a shift

away

from

early

aggressi

ve

operative

manage

ment to a

more

selective

and

conserva

tive

approach

,

however

controver


4/15

sy still

exists.

(Demetri

ades et

al. 1996)

A

thorough

review of

current

literature

has been

made to

give the

bestavailable

evidence

base; the

referenc

es are

included

at the

end of

the

chapter.

General Points about soft tissue injuries of the neck

Difficult to assess

Difficult to manage

Surgical exposure is a challenge

Controversy regarding mandatory exploration or selective

conservatism

History

First documented treatment of vascular injury in the neck Ambrose

Pare 1510-1590

1803, Fleming ligated lacerated common carotid artery

2nd world war, 851 cases of neck injury were reported with a 7%


5/15

mortality, in Vietnam this rose to 15% (Thal 1988)

1944, Bailey proposed early exploration of all cervical haematomas

on the basis of wartime experience (Bailey 1944)

1956, Fogelman and Stewart (Fogelmann & Stewart 1956) reported

a series of 100 patients showing a mortality of 6% in patients

undergoing early neck exploration versus 35% for those whose

exploration is delayed. They advocated mandatory, early exploration

of any wound penetrating the platysma.

Subsequently the rate of negative neck explorations increased and

the operative mortality fell leading to a selective approach to

management challenging this older dictum (Asensio et al. 1991)

Neck anatomy

The anatomy of the neck is unique as it contains many vital structures

representing the most important body systems. Traditionally an anatomical

scheme to look at the neck uses triangles, each triangle containing different

vital structures and coated by muscle, fascia and skin. Classically the neck is

divided into anterior and posterior triangles by the sternocleidomastoid

muscle.

The anatomical structures in the neck structures are invested by two fascial

layers:

1. The superficial fascia lies just beneath the skin and encompassesthe body of platysma (a thin superficial muscle that originates over

the upper part of the thorax and passes over the clavicles across the

neck and blends with the superficial musculo-aponeurotic system

(SMAS) of the face).

2. The deep cervical fascia can be subdivided into investing, pre-

tracheal and pre-vertebral layers.

The investing fascia encompasses the sternocleidomastoid,

omohyoid and trapezius muscles as it encircles the neck.

The pre-tracheal fascia attaches to the thyroid and cricoid cartilages

and blends with the pericardium in the thorax. It encloses the major

neck viscera (thyroid gland, trachea & oesophagus)

The pre-vertebral fascia encompasses the pre-vertebral muscles

and blends with the axillary sheath, which houses the subclavian

vessels.

The carotid sheath is formed by all 3 components of the deep fascia.


6/15

Anatomy

Neck contains structures representing different systems:

Cardiovascular

Respiratory

Digestive

Endocrine

Central nervous system

Such tight fascial compartmentalisation of the neck structures limits external

bleeding from vascular structures (Fig. 1). This beneficial effect is countered

by the dangers of bleeding within these closed spaces, which can

compromise the airway.

Figure 1: Cross sectional view of cervical fascial planes (from Gray SW,

Skandalis JE, McClusky DA: Atlas of Surgical Anatomy. Baltimore, Williams &

Wilkins, 1985, p15, with permission).

Penetrating neck injury is most commonly referred to in terms of zone of

injury (Fig. 2), rather than triangles. This is because this allows knowledge of

the possible structures involved, the need for additional specialised


7/15

investigations, surgery and prognosis.

Figure 2: Anatomic zones of the neck (from Feliciano, Moore & Mattox:

Trauma 3rd edition. Appleton & Lange 1996, p330, with permission).

Anatomic zones of injury

Zone Boundaries Structures at risk

I

Clavicles inferiorly to

the inferior aspect of the

Cricoid cartilage

Proximal Common

Carotid, Vertebral and

Subclavian Arteries

Major vessels of the

Superior Mediastinum,

Apices of the lungs

Oesophagus, Trachea and

Thoracic Duct

II

Cricoid cartilage

inferiorly up to the

angle of the mandible

Carotid and Vertebral

Arteries and Internal

Jugular Vein

Larynx, Trachea &

Oesophagus

Vagus nerve, Recurrent


8/15

(Note - Some authors use the inferior border of the mandible as the upper

boundary of zone 2) (Demetriades et al. 1997)

Mechanisms of injury

Classification of neck injury can be accomplished in different ways. The

anatomical site of injury and the related structures are vital, however the

history, mechanism and pattern of injury also give us important information

and clinicians should get as much history as possible from the pre-hospital

carers / ambulance personnel.

Epidemiology

The typical victim sustaining a penetrating neck wound is male in his

late 20s (Miller & Duplechain 1991)Male: Female =5:1 (Markey, Jr.,


9/15

Hines, & Nance 1975)

Although one might expect that the number of firearm injuries to

have increased over the last 30 years, both firearm and stab wounds

have increased at a comparable rate (Markey, Jr., Hines, & Nance

1975;Noyes, McSwain, Jr., & Markowitz 1986;Saletta et al. 1976)

The most common site of injury is the anterior triangle of the neck

Initial management

An ABC approach to all trauma patients has now become standard thanks

to the teaching of Advanced Trauma Life Support (ATLS). As part of this

teaching, the assessment and immediate management of life threatening

problems go hand in hand in a stepwise progression. The presence of a

bleeding neck wound shouldnt detract from an airway injury, respiratory

distress, stridor and altered level of consciousness mandating emergency

airway management. (Walls, Wolfe, & Rosen 1993) The importance of this

process cannot be emphasised too much; approximately 10% of patients with

penetrating neck injuries present with airway compromise. (Pate 1989) 25-

40% have a vascular injury (10% carotid artery), 10% have a respiratory tract

injury.

Expeditious pre-hospital transfer without intervention in the urban

environment, gives the patient with life threatening soft tissue neck injury the

best chance of survival. Airway and respiratory care are paramount and early

endotracheal intubation should be considered if patients present with

symptoms of respiratory obstruction:

Restlessness

Stridor

Air hunger

Hoarseness

Tracheal tug

Retraction of supraclavicular, intercostals or epigastric areas

Cyanosis

Inability to swallow and drooling

Prophylactic intubation is preferred in as controlled a fashion as possible

rather than emergency intubation, cricothyroidotomy or tracheostomy.

Patients should be assessed and initially treated in a Trendelenburg position

in order to minimise the chances of air embolism.

Direct pressure is used to control external haemorrhage. Vascular access


10/15

should be attained, ideally on the contra-lateral side to the injury and blood is

taken for cross-match of 6 units of packed red blood cells. If bleeding cannot

be controlled by direct pressure, balloon-tamponade may be attempted

(Gilroy et al. 1992), however blind / non-selective clamping of vessels should

be avoided to prevent further injury to structures.

The insertion of a nasogastric tube at this early stage should be avoided to

keep patient agitation to a minimum and to prevent bleeding which had

previously been controlled.

Demetriades (Demetriades, Asensio, Velmahos, & Thal 1996) suggests an

algorhythmn for evaluation of penetrating neck injuries (Figure 3)

Figure 3: Algorithm for neck injury evaluation (with permission)

There are other schemes based on findings in zones of the neck, (Klyachkin

et al. 1997;Velmahos et al. 1994). The basic aim is to have a fast and

effective method of assessment, so that injuries are not missed and overtreatment avoided.

A chart to aid the examination and recording of this type of injury has been

proposed by Demetriades et al (Figure 4). Some authors feel that

examination alone is sufficient in the assessment of Zone 2 neck injuries

whilst others feel that it is reliable in all Zones (Demetriades et al.


11/15

1995;Demetriades, Theodorou, Cornwell, Berne, Asensio, Belzberg,

Velmahos, Weaver, & Yellin 1997;Jarvik et al. 1995;Kendall, Anglin, &

Demetriades 1998;Velmahos, Souter, Degiannis, Mokoena, & Saadia 1994).

We feel that this chart allows a methodical examination of the structures

involved in penetrating neck injury and serves as a template for notes and

research. Its universal adoption would allow better communication (Atta &

Walker 1998).

Emergency Treatment

ABC approach

Direct pressure to control bleeding

Immediate transfer to hospital

Thorough clinical examination

Operate or investigate


12/15

Figure 4: From Demetriades D, Asensio JA, Velmahos G et al; Surgical

Clinics of North America 76:664, 1996 (with permission)


13/15

Investigations

Investigations available Indications

Plain lateral cervical spine X-

Ray

All patients

CT Stable patients with foreign

body, laryngotracheal or

oesophageal injury suspected

Angiography Injury to all Zones I-III in

haemodynamically stable pts*

Colour flow Doppler 4 QUOTE

"(Demetriades, Theodorou,Cornwell, III, Weaver, Yellin,

Velmahos, & Berne

1995;Demetriades, Theodorou,

Cornwell, Berne, Asensio,

Belzberg, Velmahos, Weaver, &

Yellin 1997;Ginzburg et al.

1996;Peter Corr, ATO Abdool

Carrim, & John Robbs 1999)"

Adve

rtise


14/15

Curr

ently

onlin

e

We

have 10

0

guests o

nline
http://www.worldortho.com/dev/index.php?option=com_banners&task=click&bid=3


15/15

Links

Stati

stics

Member

s : 335

Content

: 2220

Content

View

Hits :

4116637

Powered byJoomla!. valid XHTMLandCSS
http://www.joomla.org/http://www.joomla.org/http://validator.w3.org/check/refererhttp://validator.w3.org/check/refererhttp://jigsaw.w3.org/css-validator/check/refererhttp://jigsaw.w3.org/css-validator/check/refererhttp://www.joomla.org/http://www.joomla.org/http://www.joomla.org/http://validator.w3.org/check/refererhttp://validator.w3.org/check/refererhttp://validator.w3.org/check/refererhttp://jigsaw.w3.org/css-validator/check/refererhttp://jigsaw.w3.org/css-validator/check/refererhttp://jigsaw.w3.org/css-validator/check/referer

Documents

Neck ( Non Spinal ) Injuries