Penetrating Neck Injuries (PNI) JHSGR 22 Oct 2011 Stephanie HY Lau Queen Elizabeth Hospital

Penetrating Neck Injuries Penetrating Neck Injuries (PNI)(PNI)JHSGR 22 Oct 2011JHSGR 22 Oct 2011

Stephanie HY LauQueen Elizabeth Hospital

The NeckThe Neck

Vital structures in Vital structures in close proximityclose proximity

Single traumatic Single traumatic event can lead to event can lead to multi-system multi-system injuriesinjuries

Definition of PNIDefinition of PNI

Injuries of the neck that violates the platysma

IncidenceIncidence

In USA:

1% of all trauma patients

Brywczynski JJ et al. Management of penetrating neck injury in the emergency Brywczynski JJ et al. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J 2008; 25: 711-715department: a structured literature review. Emerg Med J 2008; 25: 711-715

Timely Management is Timely Management is CriticalCritical

Exsanguination and Exsanguination and airway obstruction airway obstruction most common most common

Mortality for major Mortality for major vascular injuries vascular injuries can reach 50%can reach 50%

Delay can result in Delay can result in devastating devastating outcomeoutcome

Three Anatomical ZonesThree Anatomical Zones

Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4Roon AJ, Christiansen N. Evaluation and treatment of penetrating injuries of the neck. J Trauma, 1979;19:391-4



Zone IZone I



Zone IIZone II



Zone IIIZone III

Crossing ZonesCrossing Zones

Zone boundaries Zone boundaries can be can be transgressedtransgressed

Superficial wound Superficial wound does not does not correspond well to correspond well to deeper structures deeper structures injuredinjured

Initial ManagementInitial ManagementDictated by ATLS guidelinesDictated by ATLS guidelines

AirwayAirwaySecuring the airway is the first Securing the airway is the first and most important stepand most important step

Definitive airway advocated in Definitive airway advocated in significant injuries or significant injuries or respiratory difficulty respiratory difficulty

Orotracheal intubation is Orotracheal intubation is primary approach unless primary approach unless contraindicatedcontraindicated

Double set up for surgical Double set up for surgical airway airway

Control BleedingControl Bleeding

Do not explore wounds Do not explore wounds in the ED in the ED

Apply direct pressure to Apply direct pressure to bleeding woundsbleeding wounds

Foley catheter can be Foley catheter can be inserted into wound for inserted into wound for tamponade effecttamponade effect

C-Spine Immobilization?C-Spine Immobilization?

Eastern Association for the Surgery of Trauma (EAST) Practice guidelinesEastern Association for the Surgery of Trauma (EAST) Practice guidelinesBrywczynski JJ et al. Management of penetrating neck injury in the emergency department. Em Med J Brywczynski JJ et al. Management of penetrating neck injury in the emergency department. Em Med J 2008; 25:711-52008; 25:711-5

Further ManagementFurther ManagementUnstable vs Stable PatientsUnstable vs Stable Patients

Penetrating Neck Penetrating Neck InjuriesInjuries


StableStableStableStableUnstableUnstable““Hard SignsHard Signs””

UnstableUnstable““Hard SignsHard Signs””

Immediate Immediate ExplorationExplorationImmediate Immediate ExplorationExploration Zone IZone IZone IZone I Zone IIZone IIZone IIZone II Zone IIIZone IIIZone IIIZone III

SymptomaticSymptomaticSymptomaticSymptomatic AsymptomatiAsymptomaticc

AsymptomatiAsymptomaticc

CTACTACTACTA

Surgical Surgical explorationexploration


Routine CTA + Routine CTA + Esophageal Esophageal workup + workup +

BronchoscopyBronchoscopy



Surgical Surgical exploration exploration (Thoracic)(Thoracic)


DischargeDischargeDischargeDischarge

Routine CTA Routine CTA and and

esophageal esophageal workupworkup



IRIRIRIR DischargeDischargeDischargeDischargeControversyControversyControversyControversy

Mandatory Mandatory explorationexplorationMandatory Mandatory explorationexploration

Selective Selective explorationexplorationSelective Selective

explorationexploration

Routine CTA Routine CTA + esophageal + esophageal

workupworkup


workupworkup

Routine esophageal Routine esophageal workup + workup +

Observation + serial Observation + serial examinationexamination










CTACTACTACTA



















workupworkup


workupworkup












CTACTACTACTA



















workupworkup


workupworkup





Hemodynamic instability or Hemodynamic instability or ““Hard Hard SignsSigns””

•Active bleedingActive bleeding•Expanding or pulsatile haematomaExpanding or pulsatile haematoma•Absent carotid pulse, neck bruit or Absent carotid pulse, neck bruit or thrillthrill•Subcutaneous emphysema, Subcutaneous emphysema, hoarseness or dysphagiahoarseness or dysphagia•Air bubbling from woundAir bubbling from wound•Evolving strokeEvolving stroke








CTACTACTACTA



















workupworkup


workupworkup





Immediate Immediate ExplorationExploration

Neck ExplorationNeck Exploration

Incision along Incision along anterior border of anterior border of

SCMSCM

Extension - Median Extension - Median SternotomySternotomy

Most versatile incision for Zone I injuries


+ Supraclavicular lateral extension to reach most major vessels


+ Anterior left 3rd intercostal space thoracotomy to expose L subclavian and descending aorta

How Do We Manage How Do We Manage Injuries?Injuries?

Vascular Injuries - Carotid Vascular Injuries - Carotid a.a.

Best treated by surgical repairBest treated by surgical repair

Proximal internal carotid injuries not Proximal internal carotid injuries not amenable to repairamenable to repair

Ligation of proximal external carotid and Ligation of proximal external carotid and utilization of it as a conduit for restoration of utilization of it as a conduit for restoration of internal carotid flowinternal carotid flow

Ligation reserved only for those with Ligation reserved only for those with devastating neurological injuriesdevastating neurological injuries

Liekweg and Greenfield Unger et al, Brown et al

Vascular Injuries - Vertebral Vascular Injuries - Vertebral a.a.

Rare, generally well tolerated due to Rare, generally well tolerated due to excellent posterior circulationexcellent posterior circulation

Operative repair is difficultOperative repair is difficult

Best treatment option: proximal and distal Best treatment option: proximal and distal ligation or embolizationligation or embolization

Vascular Injuries - Vascular Injuries - VenousVenous

Ligation if injury beyond repair by simple Ligation if injury beyond repair by simple lateral venorrhaphylateral venorrhaphy

Repair for bilateral internal jugular or Repair for bilateral internal jugular or brachiocephalic venous injurybrachiocephalic venous injury

Bilateral ligation causes increased Bilateral ligation causes increased venous pressure and can worsen venous pressure and can worsen cerebral edemacerebral edema

Laryngotracheal InjuriesLaryngotracheal Injuries

Minor injuriesMinor injuries

Observed for 24 hours Observed for 24 hours

Head of bed elevation + anti-reflux medicationHead of bed elevation + anti-reflux medication

Severe injuries (mucosal lacerations, exposed Severe injuries (mucosal lacerations, exposed cartilage, displaced fractures or unstable cartilage, displaced fractures or unstable cartilaginous skeleton)cartilaginous skeleton)

Primary repair with precise reduction and Primary repair with precise reduction and restoration of laryngeal architecturerestoration of laryngeal architecture

Pharyngoesophageal Pharyngoesophageal InjuriesInjuries

Pharyngeal lesionsPharyngeal lesions

Simple primary repair and Simple primary repair and drainagedrainage

Pyriform sinus, cricopharyngeus Pyriform sinus, cricopharyngeus and esophagusand esophagus

Primary 2-layer closure and Primary 2-layer closure and muscle flap for coveragemuscle flap for coverage

Stable PatientsStable PatientsDictated by ZonesDictated by Zones








CTACTACTACTA



















workupworkup


workupworkup












CTACTACTACTA



















workupworkup


workupworkup












CTACTACTACTA



















workupworkup


workupworkup





Zone I and III InjuriesZone I and III InjuriesDifficult surgical accessDifficult surgical access

Routine workup with angiogram + esophageal Routine workup with angiogram + esophageal workupworkup

Zone I patients: Additional bronchoscopy Zone I patients: Additional bronchoscopy

Rule out occult injuriesRule out occult injuries

PositivePositive

Useful to decide incision (Zone I) and to Useful to decide incision (Zone I) and to consider endoluminal intervention (Zone III)consider endoluminal intervention (Zone III)








CTACTACTACTA



















workupworkup


workupworkup





Zone II InjuriesZone II Injuries

SymptomaticSymptomatic

Surgical exploration with pre-operative Surgical exploration with pre-operative angiogramangiogram








CTACTACTACTA



















workupworkup


workupworkup





Should We Explore All Should We Explore All Asymptomatic Zone II Asymptomatic Zone II Injuries?Injuries?

Historical BackgroundHistorical Background

Before 1950s: Conservative managementBefore 1950s: Conservative management

1950s: Mandatory exploration1950s: Mandatory exploration

Reduction of mortality from 15% to 5% during WWIIReduction of mortality from 15% to 5% during WWII

60% negative exploration although with low morbidity60% negative exploration although with low morbidity

1980s: Selective exploration 1980s: Selective exploration

Availability of additional investigationsAvailability of additional investigations

Similar morbidity and mortality, avoids unnecessary explorationSimilar morbidity and mortality, avoids unnecessary exploration

Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.Biffl WL et al 1997: 18 year prospective study showed selective management of PNI safeBiffl WL et al 1997: 18 year prospective study showed selective management of PNI safe

Additional InvestigationsAdditional Investigations

Esophageal InjuriesEsophageal Injuries

Esophagography with water-soluble contrastEsophagography with water-soluble contrast

85% sensitivity and specificity85% sensitivity and specificity

Increased to near 100% by addition of Increased to near 100% by addition of esophagoscopyesophagoscopy

Vascular InjuriesVascular Injuries

CT angiogramCT angiogram

Leonard JW et al. Penetrating Neck Injuries: Diagnosis and Selective Management. Current Leonard JW et al. Penetrating Neck Injuries: Diagnosis and Selective Management. Current Therapy of Trauma and Surgical Critical CareTherapy of Trauma and Surgical Critical Care

Shift of ParadigmShift of ParadigmFrom era of mandatory exploration to From era of mandatory exploration to more selective managementmore selective management

Mandatory ExplorationMandatory Exploration

Still a safe diagnostic and therapeutic Still a safe diagnostic and therapeutic option if additional evaluation or option if additional evaluation or observation is not feasibleobservation is not feasible

SummarySummary

PNI often leads to multi-system injuries PNI often leads to multi-system injuries with significant morbidity and mortality with significant morbidity and mortality due to close proximity of vital structuresdue to close proximity of vital structures

Initial management follows standard ATLS Initial management follows standard ATLS protocolprotocol

SummarySummary

Unstable patients require immediate explorationUnstable patients require immediate exploration

Formal exploration used to be mandatory for all Formal exploration used to be mandatory for all Zone II injuriesZone II injuries

With advancement in diagnostic studies, stable With advancement in diagnostic studies, stable and asymptomatic patients can now be further and asymptomatic patients can now be further evaluatedevaluated

Delineate sites of injuryDelineate sites of injury

Facilitate planning of surgical or IR approachFacilitate planning of surgical or IR approach

Avoid missing significant injuries and to prevent unnecessary Avoid missing significant injuries and to prevent unnecessary explorationexploration

Thank YouThank You

Documents

Penetrating Neck Injuries (PNI) JHSGR 22 Oct 2011 Stephanie HY Lau Queen Elizabeth Hospital