Penetrating Neck Trauma

1. Penetrating Neck Trauma Umut Sarpel PGY-4

2. Case Presentation 31M No PMHx Single GSW to neck Handgun at 15 ft range

3. Case Presentation Hemodynamically stable 130/75, 86, 18, 99% on NC Spontaneous, regular respirations

4. Exam 0.5 cm entry wound at midline in Zone I No exit wound Small hematoma, no active bleeding No crepitus Breath sounds b/l 2+ pulses b/l UE 4/4 strength, sensation b/l CN II-XII grossly intact

5. Management Labs - Hct 44 otherwise unremarkable CXR obtained

7. Management CXR: R hemothorax R chest tube ? 500 cc blood Flexible laryngoscopy ? no obvious injury Airway control ? fiberoptic awake nasotracheal intubation by anesthesia

8. Management Angiogram obtained:

13. Operative Course Median sternotomy Pseudoaneurysm of brachiocephalic artery Proximal/distal control Interposition graft with PTFE from brachiocephalic to subclavian artery

14. Operative Course Injury to brachiocephalic vein noted; controlled and ligated Neck dissection ? no tracheal injury Rigid esophagoscopy ? no injury noted

15. Post-Op Course Post-op head CT: no infarct SICU: ventilatory support Moderate output from chest tube 2U PRBC on POD#3 Neurologically intact Progressive vent weaning

16. Overview Complex anatomy, many organ systems, each requiring evaluation: Vascular Respiratory Digestive Neurologic Endocrine Skeletal

18. Overview Anatomy Signs / symptoms of injury Evaluation Management

19. Anatomy: Zones

20. Anatomy: Zones Zone I � inferior trachea and esophagus vessels of the root of the neck: the brachiocephalic trunk, the subclavian arteries, the common carotid arteries, the thyrocervical trunk and the corresponding veins, thoracic duct, thyroid gland, spinal cord. Zone II � the larynx, hypopharynx common carotid arteries the internal and external carotid arteries the internal jugular veinsand cranial nerves 10, 11, and 12, the spinal cord. Zone III � the pharynx carotid arteries, the vertebral arteries, the internal jugular veinsZone I � inferior trachea and esophagus vessels of the root of the neck: the brachiocephalic trunk, the subclavian arteries, the common carotid arteries, the thyrocervical trunk and the corresponding veins, thoracic duct, thyroid gland, spinal cord. Zone II � the larynx, hypopharynx common carotid arteries the internal and external carotid arteries the internal jugular veinsand cranial nerves 10, 11, and 12, the spinal cord. Zone III � the pharynx carotid arteries, the vertebral arteries, the internal jugular veins

21. Signs: Vascular Injury Shock Hemorrhage Hematoma Evolving stroke Pulse differential in upper extremities Bruit or thrill

22. Signs: Laryngotracheal Injury Subcutaneous emphysema Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia

23. Signs: Esophageal Injury Often clinically silent Milder subcutaneous emphysema Bloody saliva Dysphagia or odynophagia Fever (late)

24. Signs: Spinal Injury Neurologic defect Spinal shock Hypotensive, often not tachycardic (But in a hypotensive trauma pt, always assume hemorrhagic shock first)

25. Mechanism Stab wound What you see is what you get GSW Unpredictable trajectory Thermal injury Maintain high level of suspicion

26. Table 1 � Mortality has decreased over the years Most still due to exsanguination Table 2 � McConnel paper combined data from 1963-1990 papers (2,495 pts) Most common sight of injury is aerodigestive tract (20%) IJ was the most commonly injured vessel followed by carotid.Table 1 � Mortality has decreased over the years Most still due to exsanguination Table 2 � McConnel paper combined data from 1963-1990 papers (2,495 pts) Most common sight of injury is aerodigestive tract (20%) IJ was the most commonly injured vessel followed by carotid.

27. Evaluation Old standard: formal neck exploration for all penetrating trauma that violates platysma Was a/w 50% negative exploratory rate New focus on directed exams: angiography, esophagoscopy, esophagography, laryngoscopy

28. Management: Vascular Injuries Zone II vascular injuries readily apparent Zone I and III injuries more difficult to detect due to anatomical constraints: 32% of pts w/ major Zone I vascular injury had no localizing PE findings

29. Management: Vascular Injuries Angiography: adjunctive diagnostic tool Arteriogram can also be therapeutic w/ embolization (works esp well in Zone III where vessels are smaller) Duplex exam: in qualified centers may be acceptable alternative

30. Management: Vascular Injuries In general, vessels should be repaired rather than ligated Carotid injuries should be repaired unless there is an already established dense neurologic deficit w/ edema (revascularization may convert ischemic to hemorrhagic infarct) If bypass is needed, PTFE preferred over saphenous vein graft

32. Management: Esophageal Injury Early detection of injury is paramount If repaired < 24hrs, survival 90% If > 24 hours, survival 64% Best detected by combination of esophagoscopy and esophagography (sensitivity near 100%) Rigid / flexible endoscopy both acceptable

33. Management: Esophageal Injury Operative repair: Primary closure is ideal (esp < 24 hrs) Close over a T-tube Buttress w/ muscle flaps or pleura Divert with esophageal stoma Widely drain Fistula rate up to 57% Consider routine swallow studies

34. Management: Tracheal Injury Thorough laryngoscopy Primary repair is the rule, tracheal mobility allows closure of defects up to 2-3cm Tracheotomy rarely indicated, only for a large defect (increases risk of infection) Absorbable suture Entry incision in the cricoid cartilage, extend in the midline to the thyroid membrane, and meticulously close mucosal lacerations, using advancement flaps if necessary, or rarely, grafts. Wire vs. miniplate fixation of cartilaginous fractures.Entry incision in the cricoid cartilage, extend in the midline to the thyroid membrane, and meticulously close mucosal lacerations, using advancement flaps if necessary, or rarely, grafts. Wire vs. miniplate fixation of cartilaginous fractures.

35. Management: Spinal Injury Can only prevent further injury Steroids appear to have some benefit in blunt trauma, but no evidence for routine use in penetrating trauma

36. Algorithm A large amount of literature accumulated showing mandatory exploration is not always necessary.A large amount of literature accumulated showing mandatory exploration is not always necessary.

37. Conclusions Know your anatomy Neck exploration is no longer mandatory in asymptomatic pts Physical exam is probably the most useful diagnostic tool (esp Zone II) Non-invasive diagnostic / therapeutic modalities should be utilized