Penetrating Neck Trauma

1. Nothing begins and nothing ends, that is not paid with moan; For we are born in other’s pain, And perish in our own. Francis Thompson, 1859-1907

3. Penetrating Neck Trauma Dr. Brook Assefa, MD, PhD (French Board) ENT-Head and Neck Surgeon Chairman of ENT-HNS Department Al Jahra Hospital

4. Outline • Introduction • Definition • Vocabulary • Frequency • Etiology / Pathophysiology • Classification • Management

5. Introduction • mandatory exploration / selective non-operative management • new diagnostic and therapeutic modalities • structures at risk in PNI the airway vascular structures the oesophagus spinal column, the spinal cord the lower cranial nerves the brachial plexus the thoracic duct

7. Neck wounds that extend deep to the platysma.

9. Vocabulary • Penetrating Neck Injuries • Penetrating Cervical Injuries • Traumatic Neck Injuries • Low / High Velocity Injuries • Wounds Deep To The Platysma

10. Frequency • 5-10 % of all traumas; trauma admission • 11% mortality rate • 30%, other injuries (multisystem injuries) • major vessel injury, fatal in 65% of cases • 2%, cervical spine injuries • Blunt: 2/3 • Open: 1/3

11. Etiology • Stab Wounds • Gun Shot Wounds • R. T. A. • Accidental PNE • War

12. The formula for the relationship between the severity of projectile injury and the kinetic energy that the missile imparts to the target tissue KE = ½ M (v1-v2)2 • KE = kinetic energy of the missile • M = missile mass • V1 = entering velocity • V2 = exiting velocity7

13. Pathophysiology • Impact Velocity KE = 1/2MV2 • Low-Velocity Injuries low wounding capacity stab wounds-knives, glass disrupt only the structures penetrated • Medium-Velocity Injuries handguns & pellet guns large amount of tissue injury; transmitted high KE • High-Velocity Injuries High wounding capacity Military Rifles, shrapnel Higher Mortality Rate

22. Classification • Roon and Christensen, 1979 • Anatomical zones • Zone I, Zone II, Zone III • Crossing boundaries • Superficial wound may not correspond to injury of deep structures • Standard Treatment

26. Zone I, 12-15% Limits: clavicles - cricoid cartilage Contents: • great vessels of superior mediastinum • the subclavian and innominate vessels • the common carotids • lower vertebral arteries and the jugular veins • trachea, esophagus angiography

27. Zone I Injuries • fatal, potential for injury to the great vessels, the cervical and thoracic esophagus • routine angiography of the aortic arch and great vessels, along with an esophageal evaluation-whether or not symptomatic • one-third of patients with zone I injury, asymptomatic • angiography of the great vessels +/- midline sternotomy or thoracotomy • contrast esophagography ~ 80% to 90% • esophagoscopy and esophagography ~ 100%. 

28. Zone II • Limits: cricoid –angle of mandible • Contents: carotids, vertebral arteries, jugular veins pharynx, larynx, esophagus, trachea • most frequent, 70-81% • neck exploration / expectant treatment

30. Zone III Limits: angle of the mandible - mastoid process Contents: • great vessels, cranial nerves branches of the carotids, vertebral artery internal jugular and facial veins • angiography

32. Zone III Injuries, 4% • skull base major blood vessels & cranial nerves INJURY ICA ECA branches vertebral artery • one-fourth; arterial injuries may be asymptomatic • temporarily stabilized by pressure • interventional radiologist, diagnostic angiogram

37. Major Injuries • Vascular Injuries • Laryngeal and Tracheal Injuries • Pharyngeal Esophageal and Injuries • Neurologic Injuries

38. Diagnosis • Physical examination, very useful • Endoscopy; laryngo-broncho-esophagoscopy • Pain X-ray; neck, chest • C-T Scan, with contrast dynamic C-T angio • Doppler • Angiography

39. Management

40. ATLS • Airway maintenance with cervical spine protection: assess the airway • Breathing and ventilation:  chest examination airway obstruction pneumothorax, haemothorax flail chest pulmonary contusion cardiac tamponade • Circulation with hemorrhage control, 2 large-bore IV lines • Disability/Neurologic assessment basic neurological assessment, AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive) E. Exposure, evaluation and environmental control undressing the patient prevent hypothermia, warm IV fluids should, maintain a warm environment

42. AdvancedTraumaLifeSupport • ATLS, TREATMENT PRIORITY • Airway jaw thrust, chin lift, suction, intubation, Cricothyroidotomy • Breathing Ventilation, oxygenation Chest needle, decompression Tube, thoracotomy • Circulation hemorrhage control, IV line, central line, venous cut down fluid resuscitation, blood transfusion pericardiocentesis, cardiac tamponade

43. AdvancedTraumaLifeSupport • Disability burr holes for trans-tentorial herniation IV mannitol • Exposure evaluation, other wounds

49. Vascular Injuries “the clock starts ticking” • Consequences Blood loss Progressive ischemia Tissue necrosis • most common injury • most common cause of death

50. Vascular Injuries • 40% of PNI 10% carotid artery injury • Presentation Hematoma (46%) Bleeding (22%) neurologic finding shock