management of neck trauma

1. Neck trauma Done by: Dr. ahmad m. aldhafeeri R1. ORL-H&N surgery 1

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4. Type of neck injury - Penetrating Gunshot wound Stab wound - Blunt MVA Sport injury Strangulation Blows 4 dr.ahmad aldhafeeri

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7. Zone I6 dr.ahmad aldhafeeri

8. ۞ Zone I ۞ Bound superiorly by the cricoid and inferiorly by the sternum and clavicles - The great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, and jugular veins), - Aortic arch - Trachea - Esophagus - Lung apices 7 dr.ahmad aldhafeeri

9. ۞ZONE II ۞Bound inferiorly by the cricoid and superiorly by the angle of the mandible - Carotid and vertebral arteries - Jugular veins - Pharynx, Larynx, Trachea - Esophagus, base of the tunge - Phrenic , vagus , and hypoglossal nerves ۩ Injuries here are seldom occult ۩ Common site of carotid injury 8 dr.ahmad aldhafeeri

11. morbidity and mortality Zone I injuries are associated with the highest morbidity and mortality rates. more common among males than females. Most are adolescents and young adults 10 dr.ahmad aldhafeeri

12. Neck trauma accounts for 5-10% of all serious traumatic injuries missed cervical injuries secondary to neck trauma result in a mortality rate of greater than 15%. 10% of neck wounds lead to respiratory compromise. Loss of the airway patency may occur precipitously, resulting in mortality rates as high as 33%. 11 dr.ahmad aldhafeeri

13. Frequancy Thrombosis is the most common complication of vessel injury, occurring in 25-40% the most common sites of vascular injuries internal jugular vein (9%) and carotid artery (7%). Injury to the pharynx or the esophagus occurs in 5-15% of cases. The larynx or the trachea is injured in 4-12% of cases. Major nerve injury occurs in 3-8% of patients sustaining penetrating neck trauma. 12 dr.ahmad aldhafeeri

14. Vascular injury Hard evidence: sever active hemorrhage, shock unresponsive to volume expansion, absent ipsilateral upper extremity, neurologic deficit Soft evidence: bruit, widened mediastinum , hematoma Decreased upper extremity pulse, shock response to volume expansion 13 dr.ahmad aldhafeeri

15. Laryngotracheal injury Subcutaneous emphysema Airway obstruction Sucking wound Stridor Dyspnea Hemoptysis Hoarseness Dysphonia 14 dr.ahmad aldhafeeri

16. Pharynx/esophagus injury Subcutaneous emphysema, Hematemesis Dysphagia Odynophagia 15 dr.ahmad aldhafeeri

17. Approach & Management 16 dr.ahmad aldhafeeri

18. Airway Breathing Intubation vs. Surgical Airway Circulation IV access, Immediate Exploration disability exposure Primary survey 17 dr.ahmad aldhafeeri

19. Established Airway be prepared to obtain an airway emergently intubation or cricothyrotomy Be a ware of cutting the neck in the region of the hematoma -- disruption there may lead to massive bleeding must assume cervical spine injury until proven otherwise 18 Airway dr.ahmad aldhafeeri

20. Zone I injuries with concomitant thoracic injuries pneumothorax hemopneumothorax tension pneumothorax 19 Breathing dr.ahmad aldhafeeri

21. Bleeding should be controlled by pressure Do not clamp blindly or probe the wound depths The absence of visible hemorrhage does not rule out Two large bore IVs Careful of IV in arm unilateral to subclavian injury Do not remove objects protruding from the neck in the ER 20 Circulation dr.ahmad aldhafeeri

22. Cross-match, hematologic analysis, chemistries, urinalysis, coagulation profile, blood gas, toxicologic analysis B-hCG for female Urine cath. CXR – inspiratory /expiratory films to assess the lung, mediastinum and any phrenic nerve injury Cervical spine film to rule out fractures Soft tissue neck films AP and Lateral Arteriograms, contrast studies as indicated 21 dr.ahmad aldhafeeri

23. Obtain from any witnesses or patient Mechanisms of injury - stab wounds, gunshot wound, high-energy, low-energy, trajectory of stab Estimate of blood loss at scene Any associated thoracic, abdominal, extremity injuries Neurologic history 22 Secondary survey history dr.ahmad aldhafeeri

24. Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits Neuro exam: mental status, cranial nerves, and spinal column Examine the chest, abdomen, and extremities Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here Don’t blindly explore wound or clamp vessel 23 examination dr.ahmad aldhafeeri

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26. Zone I Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy suspicion must be great before taking the patient to OR becausehigh mortality rate. Cardiothoracic surgery consultation a must 4 vessel Angiography is advocated by surgeon because difficulty of identify injury intraoperative 2 prospective study show only 5% of zone I injury need operation 25 dr.ahmad aldhafeeri

27. Zone II Few injuries will escape clinical examination Most carotid injuries occur here algoriyhm *Several study have suggest of contrast enhance CT to demonstrate the injury and aid for further invasive investigation or exploration *Furthermore studies shown CT angio. More to be useful and comparable to conventional angiography in evaluation vascular inj. 26 dr.ahmad aldhafeeri

28. *Finally some expert recommend ipsilateral exploration despite increase incidence of negative exploration and increase hospital cost None of these algorithm for management of penetrating zone II had shown superiority over the others* 27 dr.ahmad aldhafeeri

29. Zone III Upper neck injury with evidence of vascular injury required prompt CT angiography Embolotherapy can be used for temporary or definitive managementexcept for Ica Direct pharyngoscopy suffice to exclude aerodigestive trauma Endovascular stenting or embolization especially in zone I & III should be considered 28 dr.ahmad aldhafeeri

30. Exploration vs. Observation Many experts have adopted a policy of selective exploration Decreased number of negative explorations, increased number of positive explorations Decreased cost of medical care, maybe No increase in mortality when adjunctive diagnostic studies and serial exams performed 29 dr.ahmad aldhafeeri

31. *Exploration Most common approach in anterior of SCM Collar incision is reversed for isolated aerodigestive inj. Or for bilateral exploration Major arteries should be repaired where possible except the vertebral which can be ligated Veins can be ligated EXCEPT bilateral IJV 30 dr.ahmad aldhafeeri

32. Partial lacerations can be closed primarily -- vein patches will help prevent subsequent stenosis High velocity wounds produce a surrounding area of contusion which may be thrombogenic and which must be resected; then primary reanastamosis if possible 31 dr.ahmad aldhafeeri

33. Aerodigestive injury in EXPLORATION DL where laryngeal injury is suspected Aerodigestive should repaired primary by synthetic absorbable suture IF tandem injury occur a well vascularized flap should be interpose between the repairs to prevent aerodigestive fistula 32 dr.ahmad aldhafeeri

34. Drain-if suspect aerodigestive injury To Prevent lethal mediastinitis and In combined aerodigestive and vascular injuries the aerodigestive repair should be drained to the contralateral neck to prevent break down of the vascular repair from gastrointestinal secretion raw surfaces Cover with nasal, buccal, or local mucosal flap A keel or soft stent is placed when loss areas are opposed 33 dr.ahmad aldhafeeri

35. In central neurologic deficits: repair the artery when there are minimal deficits, with gross deficits restoration of flow can convert ischemic infarcts into hemorrhagic ones -- the artery should be ligated a deterioration in neurologic status dictates arteriography and reexploration EC-IC bypass when irreparable injury to ICA 34 dr.ahmad aldhafeeri

36. Blunt neck trauma Sever Blunt neck trauma can result in significant laryngeal and vascular injury Best modality in stable pt contrast enhance CT to demonstrate the injury and aid for further invasive investigation or exploration 35 dr.ahmad aldhafeeri

37. laryngeal injury If suspect of minor laryngeal injury can treated with airway protection, head of bed elevation and possibly antibiotics Major laryngeal injury required operative exploration and repaired 36 dr.ahmad aldhafeeri

38. Blunt vascular injury Usually involves the internal and common carotid artery there may also be injury to the vertebral vessels without symptomatology & come later with neurological deficit Four vessels angiography and CT angiography are preferred diagnostic modalities Severity of the deficits and time of diagnosis are strongly associated with outcome 37 dr.ahmad aldhafeeri

39. The current recommendation is for operative repair for surgically accessible lesions. Systemic Anticoagulant with heparin appears to improve neurologic outcome and is therefore recommended for surgically inaccessible lesions 38 dr.ahmad aldhafeeri

40. If suspect esophagial injury ESOPHAGOSCOPY /ESOPHAGOGRAM If +ve operation exploration ‘ll next step 39 dr.ahmad aldhafeeri

41. Conclusions: Maintain a healthy respect for apparently minor neck wounds because of potential fatal outcome for initially benign appearing injuries Do not try to infer trajectories of gunshot wounds from clinical or radiographic studies Careful history and complete physical exam with appropriate studies will avoid missed injuries Arteriography for zone I and zone III injuries Vascular injuries most immediately life-threatening & missed esophageal injury causes late mortality 40 dr.ahmad aldhafeeri

42. Thank you 41 dr.ahmad aldhafeeri