Neck Trauma Lec

NECK TRAUMA APOLONIO L. LASALA, MD Professor Department of Surgery Faculty of Medicine and Surgery University of Santo Tomas

Background • Few emergencies pose as great a challenge as neck trauma • Neck is a relatively small conduit where multitude of organ systems are involved – Respiratory/airway (eg. trachea) – Gastrointestinal (eg. esophagus) – Neurological (eg. cervical nerve roots, cervical spine, brachial plexus, etc.) – Vascular (eg. Carotid arteries, jugular veins, great vessels, etc.) – Musculoskeletal structures

Background • Single penetrating wound may be harmful or lethal • Therefore, a clear understanding of the anatomic relationships within the neck and the mechanisms of injury is critical to devising a rational diagnostic and therapeutic strategy

Anatomy of the Neck

Anatomy of the Neck

Anatomic Structures at Risk • Neck protected by the spine posteriorly, the head superiorly, and the chest inferiorly • Therefore, anterior and lateral regions are most exposed to injury, esp. trachea and larynx • Spinal cord lies posteriorly, cushioned by the vertebral bodies, muscles, and ligaments, therefore, more prone for blunt than penetrating injury • Esophagus and the major blood vessels are between the airway and spine

Anatomic Structures at Risk

• Musculoskeletal:

– cervical spine – cervical muscles – tendons, and ligaments – clavicles – first and second ribs – hyoid bone

• Neural structures: – spinal cord – phrenic nerve – brachial plexus – recurrent laryngeal nerve – cranial nerves (specifically IXXII) – stellate ganglion.

Anatomic Structures at Risk

• Vascular structures – carotid (common, internal, external) – vertebral arteries – brachiocephalic – jugular (internal and external) veins

• Visceral structures: – thoracic duct – esophagus – pharynx – larynx – trachea

Anatomic Structures at Risk

• Glandular structures: – thyroid glands – parathyroid glands – submandibular glands – parotid glands

Anatomic Landmarks

Anatomic Zones of the Neck

Anatomic Zones of the Neck

• Zone I

• Structures: Great vessels, trachea, esophagus • Involvement may have high mortality rate upto 12% • Osseous shield makes surgical exploration of the root of the neck difficult • R side  median sternotomy • L side  L anterior thora-

Anatomic Zones of the Neck

• Zone II

• Structures: internal & external carotid arteries, jugular veins, pharynx, larynx, esophagus, RLN, spinal cord, trachea, thyroid and parathyoids • Most frequently involved (60 to 75%)

Anatomic Zones of the Neck

• Zone III

• Structures: carotid and vertebral arteries, jugular veins, cranial nerves • Protected by skeletal structures and is difficult to explore • Recognizing injuries to the cranial nerves exiting the base of the skull in zone III is important because these injuries may be indicative of injuries • to the great vessels due to • their close proximity

Neck trauma: Zone I • Between clavicle /cricoid cartilage • Thoracic outlet – hemothorax • Stable patients – CXR – angiography – esophagography/ endoscopy – bronchoscopy

• Unstable patients – immediate exploration

Neck trauma: Zone II • Between cricoid /mandibular angle • neck proper easiest evaluation • wound exploration – platysmal penetration

• stable asymptomatic patients – Observed – Cervical spine x-ray

• symptomatic patients – explored

Neck trauma: Zone III • Above angle of mandible • require carotid/vertebral angiograms • neurologic injuries

Mechanisms of Injury • Penetrating • >95% results from stab and GSW • GSW sustain more injury than stab wounds for it damages even outside the tract • After GSW to the neck, surgery is indicated in 75% of cases • About 50% of stab wound to the neck would require surgery

Mechanisms of Injury • Penetrating • internal jugular vein 9% most common sites of vascular • carotid artery 7% injuries • pharynx 5-15% • esophagus • larynx 4-12% • trachea • major nerve injury 3-8%

Whiplash injury

WHIPLASH INJURY • Neck sprain or neck strain • An injury to the soft tissues of the neck • Often the result of rear-end car crashes

WHIPLASH INJURY • Symptoms of Whiplash • Neck stiffness • Injuries to the muscles and ligaments (myofascial injuries) • Headache and dizziness (symptoms of a concussion) • Difficulty swallowing and chewing and hoarseness • Abnormal sensation such as burning or prickling • Shoulder and back pain

WHIPLASH INJURY • Diagnosis of Whiplash • • • •

Physical exam to evaluate patient’s condition Neurological exam X-ray cervical spine to rule out cervical injuries CT scan to assess condition of the

•

• MRI

cervical spine’s soft tissues

WHIPLASH INJURY • Treatment • • • • •

Soft cervical collar to be worn 2 to 3 wks Heat therapy to relieve muscle tension and pain Pain medications (Analgesics and NSAIDS) Muscle relaxants Range of motion of exercises and physical therapy • Cervical traction

Mechanisms of Injury • Blunt • Usually from motor vehicle accident • Other causes: – sports-related injuries – strangulation – blows from the fists or feet

Mechanisms of Injury • BLUNT

• PENETRATING

• • • • • • • •

• stab – knife/icepick – sharps • gunshot wounds – small caliber – rifle/shotgun

direct blows fall frontal impact “whiplash” “clothesline” “head banging” chiropractic soccer

Signs/Symptoms of Neck Injury Shock

Dyspnea

Hemoptysis

Active Bleeding

Stridor

Dysphagia

Expanding hematoma

Hoarseness/ dysphonia

Hematemesis

Focal / Lateralized deficit

Subcutaneous Subcutaneous emphysema emphysema Vascular Vascular

Airway Airway

Esophagus Esophagus

Neurologic Neurologic

Work-ups and Diagnostic Modalities • Mainly based on the zone affected:  CBC, blood typing  Chest X-ray  Cervical spine X-ray (AP-lateralopen mouth views)  Angiography  Esophagography/endoscopy  Bronchoscopy  Carotid/vertebral angiograms  CT scan

Chest X-ray

Cervical Spine X-ray

• Lateral views must be able to visualize all cervical vertebrae (C1 to C7) because majority involves C5-C6

Cervical Spine X-ray

• Open mouth/odontoid views will be able to visualize the AP view of C1C2 • AP view can only visualize C3-C7 because of the mandible

Carotid Angiography • relatively invasive • can be done to stable patients • if CT scan is not available • less expensive but also has lower sensitivity and specificity compared to CT angiography

CT angiography • relatively invasive • can only be done to stable patients • renal function test must be normal • may delay the diagnosis and of treatment • sensitivity 97.7% • • • •

specificity 100% PPV 100% NPV 99.3% accuracy 99.3%

History of Management • 1552  Ambrose Pare ligated both common carotid • arteries and the jugular vein of a soldier w/ • a traumatic neck injury  patient survived • but developed aphasia and hemiplegia • 1803  Fleming ligated a lacerated common carotid • artery and reported a successful outcome • after 5-month follow-up

History of Management • As continual advances in anesthesia and new technologies developed, therapy has evolved Nonoperative management No treatment

Routine neck exploration Selective neck exploration

Management Algorithm

Management Algorithm

Indications for Neck Exploration • • • • • • •

Shock Expanding hematoma Active bleeding Subcutneous emphysema Hoarseness Stridor Obvious esophageal and/or tracheal injuries

Management •ABCs of Trauma •A airway • B -breathing •C circulation •Ddisability and neuorologic status • Eexposure and over-all evaluation

Management • Stabilization

• Critically injured patient – Rapidly assessing vital functions and the area of injury – Performing stabilizing interventions – Initiating a diagnostic workup – Definitive care • No immediate life threat – Violates the platysma ( explore at OR ) • * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order

Management • Medical • Resuscitative efforts with emphasis on the ABCs • Clear airway • Establish optimal airway (ie, through ET intubation) and possibly start mechanical ventilation • Control of bleeding with direct pressure • Large-bore IV catheters for fluid resuscitation • Cervical spine precaution until injury

Management • Surgical • Immediate surgical exploration if indicated • Surgical management depending on the injured structure

Neck trauma •

A 28 year old male, hold-up victim is admitted to the ER because of a punctured wound to the neck. • VS: BP: 130/90 PR: 98/min RR: 22/min ; a 3mm punctured wound is noted over the left anterior triangle of the neck,beside the thyroid cartilage. While taking his history, the patient starts to panic and complains of severe dyspnea.

Neck trauma •

A 42 yr old female is thrown against the front seat of a car during a high speed vehicular accident. She is unconscious, BP: 60 palpatory, pulse is faint and thready; both clavicles are fractured; there are no breath sounds over the left hemithorax