Neck Trauma

NECK TRAUMA General Surgery II Lecture 2 -tadgetransIII-B USTFMS ________________________________ _

Triangles of the Neck

NECK TRAUMA • •

5-6% as isolated injury Fatality rates: – stab wounds 1-2% – gunshot wounds 5-12% – rifle/shotgun 50% –

Anatomy of the Neck

preventable deaths 50%

Causes of Neck Trauma • • • •

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Blunt Trauma Diving injuries Assault Vehicular – crashing into windshield /steering wheel – seat belt – whiplash – “clothesline” Penetrating – Assault • stab wounds • gunshot wounds – Vehicular • broken glass

ZONES OF THE NECK [MONZON]

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Zones of the Neck •

avoid intubation in symptomatic/ high risk Neurologic injury

Penetrating Neck Trauma • • • •

70 - 80% of injuries vascular/aerodigestive tract injury Hemorrhage – 20-30% Mortality – 5-6 %

Signs of Significant Injury in Penetrating Neck Trauma VASCULAR INJURY • Shock • Active bleeding • Large/expanding hematoma • Pulse deficit AIRWAY INJURY • Dyspnea • Stridor • Hoarseness • Dysphonia or voice change • Subcutaneous emphysema • •

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Zone I • highest mortality Zone II • most frequent site of injury • lower mortality Zone III • neurological • distal carotids • pharyngeal injuries

Blunt Neck Trauma • •

Frequently involves C5-C6 Rescue/ transport • neck immobilization

DIGESTIVE TRACT INJURY • Hemoptysis • Dysphagia/odynophagia • Hematemesis • Subcutaneous emphysema Injured Structures from Penetrating Neck Wounds • SYSTEM INJURED PATIENTS(%) • Arterial 516 (12.3) • Venous 769 (18.3) • Digestive 354 ( 8.4)

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Respiratory 331 ( 7.8)

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Source: Adapted from JA Asensio, et al. Management of Penetrating Neck Injuries: The Controversy Surrounding Zone II Injuries In JA Asensio and JA Weigelt (eds.), The Surgical Clinics of North America Contemporary Problems in Trauma Surgery. 71:2, 1991;

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Manner of injury Pre-existing disease Vital signs location/ extent of injury neurologic deficit ? probing

Penetrating Neck Trauma Algorithm

Initial Care • ABCs of Trauma Resuscitation –

ventilation

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treatment of shock

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baseline neurologic exam

Airway Assessment • Spontaneous respiration – conscious – stridor – tachypnea – dyspnea – frothing •

No respiration – intubate – airway obstruction – shock

Hemorrhage/ Shock • Control bleeding – direct digital pressure – occult bleeding • hemothorax CTT • Venous access – fluid replacement/ blood – central line History/ Physical Exam – Time factor

Presentation • - GSW, POE: L supraclavicular, No POX, Hemorrhagic shock • - hacking wound to the neck with external bleeding; shock • - punctured wound to the neck, stable vital signs • - punctured wound to the neck. stable VS, suddenly develops dyspnea • - 1.5 cm stab wound zone II, stable vital signs with subcutaneous emphysema • - punctured wound,nape, in hypovolemic shock, unable to move or feel LLE Mandatory Exploration – negligible m/m for (-) exploration tjkg☺

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comparative cost of work-up 17-25% (+) exploration in asymptomatic patients • 83% significant injury in transcervical gunshot wounds high mortality for delayed operations: • 67% for vascular injury • 44% for esophageal injury

Selective Exploration – 40-60% incidence of negative exploration – medical cost of unnecessary surgery – availability of accurate, non-invasive diagnostic facilities – mandatory exploration based on high velocity military injuries Rules on Exploration – All symptomatic patients are explored – Work-up is irrelevant in the presence of clinical signs of injury – Zone I injuries liberally explored • difficult vascular control • disastrous consequences with delay Diagnostic work-up • Angiography • gold standard for vascular injury

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more in Zones I and III • Esophagography • water soluble/ barium contrast • 50-90% sensitivity • Esophagoscopy • 50-90% sensitivity • rigid / flexible Surgical Management • Vascular injuries – Carotid Artery • blunt injury - 2040% mortality • permanent neurologic impairment in 4060% • repair or ligation of penetrating lacerations – comatose patients – acute stroke after revasculari zation • Vertebral artery • hyperextension/rot ation • chiropractic manipulation • soccer/volleyball injury • heavy metal rock music – Usually diagnosed angiographically – thrombosis/hemorrhage Esophagus –

Difficult diagnosis

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clinically evident in 20-30% • exponential increase in MR with late diagnosis, 100% if undiagnosed Primary repair when feasible cutaneous pharyngostomy/ esophagostomy

Larynx and Trachea

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Subcutaneous emphysema, hoarseness,respiratory distress – debridement – reduction of fractures – coverage of exposed cartilage – closure of tracheal defects – tracheostomy ________________________________ _ ☺yajeetendteejay☺

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