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Neck Trauma

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by

Gregory Nicolas

on 28 April 2017

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Transcript of Neck Trauma

62
ECG
bpm
Thank You!
Type of neck injury
Important Statistics
Vascular injury
Definitive Diagnosis when :
Laryngotracheal Injury
Morbidity & Mortality
Gregory Nicolas
Neck Trauma
1- Penetrating
Gunshot wound
Stab wound

2- Blunt
MVA
Sport injury
Strangulation
Blows
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
Zone I
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

Zone III
Lies above the angle of the mandible
Carotid arteries
Jugular veins
The salivary and parotid glands
Esophagus, pharynx
Major cranial nerves

Vascular and cranial nerve injuries common
sever active hemorrhage
shock unresponsive to volume expansion
absent ipsilateral upper extremity
neurologic deficit
Less Definitive
Bruit
Widened mediastinum
Hematoma
Decreased upper extremity pulse
Shock responsive to volume expansion
Pharynx/ Esophagus Injury
Approach & Management
Primary Survey
Airway
Breathing
Circulation
Examination (Trajectory)
Secondary Survey
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
Examination
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
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
Penetrating injuries
can be dramatic
Blunt injuries
may present in a more subtle, delayed manner
Sit upright and lean forward
Keeps airway patent and allows for drainage of blood and secretions
DO NOT
attempt to lie patient flat
May be better to go to OR for intubation with preparation for surgical airway --> more controlled situation
Controversy over conversion
Traditional view (1921) – more likely to stricture
converted to trach on semi-elective basis within 24 to 48 hrs
1976 – low complications with elective cric
Recent trauma studies show higher rate of complications for conversion
Types of Weapons
Low velocity – knives, ice picks, glass
High velocity – handguns, shotguns, shrapnel

K=1/2mv^2

2 basic types of weapons – low and high velocity. As shown by formula, velocity is more important than mass in the amount of energy carried by a weapon
The main factors influencing management decisions are:
hemodynamic stability
presence of hard signs
injury location
Cervical Vascular Injuries
Neck trauma damages cervical vessels in 25% of cases
Penetrating trauma predominates
30% have associated injuries in the neck and thorax
Blunt trauma accounts for < 10% of injuries
mortality rate = 10 – 30%
Active bleeding should be controlled with digital pressure until direct vascular control is achieved
Wounds should not be probed, cannulated or locally explored
these can dislodge clot and lead to uncontrolled hemorrhage or embolism
Operative Approach
Zone I - SCM incision + sternotomy

Zone II - SCM incision

Zone III - post-auricular extension with SCM incision + mandibular subluxation
Provides exposure of the carotid sheath, pharynx and cervical esophagus
Can be lengthened to provide more extensive proximal or distal exposure
If bilateral exploration is necessary, separate incisions can be done

SCM Incision
Carotid Trauma
Injuries to the CCA or ECA are governed by the extent of injury and overall status of patient
Simple injuries to the ECA should be repaired and complex injuries ligated
Complex injuries to CCA can be ligated if no neurologic deficits
Injuries to the ICA are more problematic
Simple injuries with no interruption of flow should be repaired
Injuries to CCA or ICA with interrupted flow in the vessel, repair creates a theoretical disadvantage
Patient’s pre-op neurologic status
If there is no neuro deficit, it is presumed that there are no areas of brain ischemia --> repair is safe

Focal neuro deficit is presumed to be related to ischemia

Milder neuro deficits may respond favorably to revascularization
To Ligate or Not to Ligate
Vertebral Artery Injury

Incidence
1 – 7% with penetrating
< 1% with blunt
Mortality = 5%
Massive hemorrhage up to 15%
Neuro signs rarely found
Suspect with wounds posterior to SCM, facet joint dislocation or fracture through transverse foramen






Blunt Trauma
Full transcript