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Case #1

Case #1.

karina-webster
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Case #1

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  1. Case #1 • 41 yo male serving life in prison sentence attacked by fellow inmate with sharpened toothbrush. Sustained penetrating wound to left neck. Vitals stable in field, GCS 15, noted to have expanding hematoma over L neck. On arrival in ED having more difficulty moving air, attempts at intubation failed due to deviated trachea. Cricothyrotomy done at bedside. • Patient taken to CT scan • Vascular surgery consulted

  2. Penetrating Neck Trauma • Injuries not penetrating the platysma are superficial and require no further workup • Zone III • Angle of mandible to base of skull • Exposure of this area difficult • Pharynx; distal carotid and vertebral arteries; parotid gland; cranial nerves • Zone II • Cricoid to angle of mandible • Usually clinically apparent injuries • Cartoid and vertebral arteries; jugular vein, larynx; esophagus; trachea; vagus; recurrent nerve • Zone I • Thoracic inlet (sternal notch to cricoid • Injuries to this area have highest mortality • Proximal carotid, subclavian, vertebral arteries; upper lung; esophagus; trachea; CNS

  3. Initial Management • Airway • Endotracheal intubation for any difficulty with oxygenation, ventilation, or depressed sensorium • Obvious tracheal injury can be treated with ETT into the wound • Bleeding controlled with direct pressure • CXR and lateral C-spine films • Major vascular injury in Zone II usually clinically apparent with significant hematoma or frank external hemorrhage • Approached by immediate surgical exploration • Due to difficulties of vascular exposure in Zone I and III, angiography is needed prior to surgical exploration unless extremely unstable

  4. Indications for neck exploration • Vascular • Expanding hematoma • External hemorrhage • Airway • Stridor • Hoarseness • Dysphonia/voice change • Hemoptysis • SQ emphysema • Digestive (esophageal injuries difficult to detect in 30% patients) • Dysphagia • Blood in oropharynx • Neurologic • Lateralized neuro defect consistent with injury • altered state of consciousness not due to head injury • Preoperative workup minimal in these patients

  5. MANDATORY Low rate of complications Potentially devastating effect of delay in diagnosis of aerodigestive injuries SELECTIVE High rate of negative exploration in asymptomatic patients Low incidence of devastating complications of delay CONTROVERSY:Optimal approach for patients with Zone II injuries and no suspicious clinical findings • Current data shows similar outcome for both approaches • Selective management include various combinations of physical examination, triple endoscopy, angiography, esophagography, CT scanning, duplex

  6. Operative ManagementKuehne et al, Penetrating trauma of the ICA. Arch Surg 131:942-8, 1996.

  7. Review of the Literature • Gonzalez, et al. J Trauma 2003;54:61-65. • 42 prospective patients with Zone II underwent CT + esophagography, then exploration • 4 esophageal injuries (2/4 on CT, 2/4 on esoph) • 7 IJ injuries (4/7 on CT) • Gracias, et al. Arch Surg 2001;136:1231-5. • 23 patients with penetrating neck injuries underwent CT initially • 13 patients no injury (4 discharged from ED) • 10 patients had angiography, 2 required endoscopy due to proximity • Mazolewski, et al. J Trauma 2001;51:315-19. • 14 prospective patients with Zone II injuries underwent CT, then mandatory exploration • 4 scans deemed high probability, 3 had surgical injury • No missed injuries • Munera, et al. Radiology 2002;224:366-72. • 175 patients with penetrating neck injuries • Injuries idenitified in 27 patients (15.6%), observation in 146 • Sensitivity 90%, specificity 100%, PPV 100%, NPV 98% • One missed injury of pseudoaneurysm at common carotid origin

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