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Neck Trauma

Neck Trauma. Penetrating trauma Blunt trauma Near - Hanging & Strangulation. Penetrating Trauma. Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation. Pathophysiology. Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings

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Neck Trauma

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  1. Neck Trauma

  2. Penetrating trauma • Blunt trauma • Near - Hanging & Strangulation

  3. Penetrating Trauma Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation

  4. Pathophysiology Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous

  5. Organ System Classification • Vascular ( most common ) • Pharyngoesophageal • Laryngotracheal • Others ( cranial nerve, thoracic duct, brachial plexus, spinal cord….

  6. Vascular Three pathophysiologic mechanisms • External hemorrhage • Extending soft tissue hematoma, distort or obstruct the airway • Disruption of cerebral perfusion ( CVA )

  7. Pharyngoesophageal • Rarely causes any immediate consequence • Delayed diagnosis can lead to serious soft tissue infection, mediastinitis and sepsis

  8. Laryngotracheal • Small puncture wound • Airflow away from respiratory tree • Obstruction of airway

  9. Wound Location Classification • Anterior (Sternocleidomastoid muscle ) • Posterior • Anterior • Zone 1 ( below cricoid cartilage ) • Zone 2 ( between the cricoid cartilage and mandible angle ) • Zone 3 ( above mandible angle )

  10. Management of Penetrating Trauma Stabilization • Critically injured patient • Rapidly assessing vital functions and the area of injury • Performing stabilizing interventions • Initiating a diagnostic workup • Definitive care • No immediate life threat • Violates the platysma ( explore at OR ) * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order

  11. Airway • The risk of spinal cord injury is minimal • Cervical cord injury in a gunshot wound victim when intubation has never been reported • Preintubation radiography is significant

  12. Airway General • Most difficult management dilemma: awake patient with impending airway obstruction • Preoxygenation is important # Comatous patients & patients in respiratory distress require immediate intubation # It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED )

  13. Airway Method • Oral & nasal intubation with or without endoscopic guidance or muscle relaxants • Percutaneous transtracheal ventilation ( PTV ) • Surgical airway

  14. Airway Method • PVT • Airway remains unprotected & uncomfortable in conscious patient • Temporary intervention • Complication and contraindication 1. Significant airway obstruction & penetrated airway 2. Subcutaneous emphysema, pneumothorax

  15. Airway Method • Surgical Airway • Last resort ( direct injury to the airway is exception ) • cricothyrotomy • Tracheostomy or even intubation via the wound

  16. Hemorrhage External hemorrhage • Direct pressure • Blindly clamping bleeding vessels is avoided • Quick transfer to the operating room Inter Hemorrhage • Airway compromised • Zone 1 injury result in hemothorax ( thoracostomy )

  17. Definitive Management of Penetrating Trauma Unstable patient Immediate transfer to the OR Stable patient • General • Mandatory exploration • Selective Approach

  18. Definitive Management Stable Patient • General • Lateral neck film • CXR ( especially in zone 1 injuries ) • NG tube should not be inserted • Prophylactic antibiotics • Mandatory exploration • Selective Approach • A selective method reserves operative intervention for patients with clinical signs of significant injury

  19. Clinical Findings:Require Surgical Intervention Using a Selective Approach • Expanding or pulsatile hematoma • Presence of a bruit • Horner syndrome • Subcutaneous emphysema • Air bubbling through wound • Hemoptysis or blood - tinged saliva • Shock or active bleeding • Absent peripheral pulses • Respiratory distress Others are observed & undergo various diagnostic studies

  20. Other Diagnostic Studies • Bronchoscopy • Esophagography • Esophagoscopy • Angiography # Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies

  21. Disposition of Penetrating Neck Trauma No indication for surgery ==> admission for at least 24 hrs

  22. Blunt Trauma • Rare, compared with penetrating trauma • Motor vehicle crash or an assault • Off - road vehicles

  23. Classification of injuries • Larygotracheal • Pharyngoesophageal • Vascular : delayed dissection or thrombosis ( CVA )

  24. Four recognized mechanisms by which thrombosis can occur • A direct blow to the neck • A blow to the head that causes hyperextension and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels • Blunt intraoral trauma • Basilar skull fracture

  25. Spinal column and spinal cord injuries are more prevalent in blunt trauma

  26. Clinical Feature Physical findings may be lacking , it is important to elicit symptoms 1 .Dysphagia, odynophagia 2.Voice quality 3.Aphonia, muffled voice ( serious injury )

  27. Management of Blunt Neck Trauma Whether the patient has laryngotracheal injury?

  28. Definitive Management General • C - spine X-ray • CXR Additional Studies • Laryngotracheal • Vascular • Pharyngoesophageal

  29. Additional Studies • Laryngotracheal • Plain radiographs • CT • endoscopy ( fiberoptic bronchoscopy ) ( Consult chest surgeon or ENT ? ) • Vascular • Angiography • Color Flow Doppler ultrasound • Pharyngoesophageal • Threshold for performing diagnostic studies should be low • Esophagram & esophagoscope ( Consult chest surgeon )

  30. Disposition of Blunt Neck Trauma • Laryngeal injuries do not require immediate repair • Tracheal injuries should receive prompt surgical attention

  31. Near - Hanging & Strangulation Classification of Strangulation • Hanging ( most common ) • Ligature strangulation • Manual strangulation • Postural strangulation

  32. Clinical Features • Superficial & Deep Neck • Respiratory (delayed mortality) • Bronchopneumonia • Aspiration pneumonitis • Delayed airway obstruction • ARDS • Neuro psychiatric

  33. Management • Spinal cord injury is very rare • Phenytoin: useful in preventing ischemic cerebral damage • Naloxone • Ca2+ channel blocker

  34. Summary Structured approach to these patients, regardless of mechanism is essential to optimize outcome & avoid catastrophe

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