Neck Trauma

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Neck Trauma
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• Penetrating trauma
• Blunt trauma
• Near - Hanging Strangulation

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Penetrating Trauma

• Symptoms of injuries to structures
• such as the esophagus can be
• subtle or delayed in presentation

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Pathophysiology

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

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Organ System Classification

• Vascular ( most common )
• Pharyngoesophageal
• Laryngotracheal
• Others ( cranial nerve, thoracic duct, brachial
  plexus, spinal cord.

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Vascular

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

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Pharyngoesophageal

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

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Laryngotracheal

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

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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 )

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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

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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

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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 )

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Airway

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

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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

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Airway

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

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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
  )

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Definitive Management of Penetrating Trauma

• Unstable patient
• Immediate transfer to the OR
• Stable patient
• General
• Mandatory exploration
• Selective Approach

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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

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Clinical FindingsRequire 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

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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

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Disposition of Penetrating Neck Trauma

• No indication for surgery gt admission for at
  least 24 hrs

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Blunt Trauma

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

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Classification of injuries

• Larygotracheal
• Pharyngoesophageal
• Vascular delayed dissection or thrombosis (
  CVA )

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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

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

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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 )

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Management of Blunt Neck Trauma

• Whether the patient has
• laryngotracheal injury?

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Definitive Management

• General
• C - spine X-ray
• CXR
• Additional Studies
• Laryngotracheal
• Vascular
• Pharyngoesophageal

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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 )

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Disposition of Blunt Neck Trauma

• Laryngeal injuries do not require immediate
  repair
• Tracheal injuries should receive prompt surgical
  attention

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Near - Hanging Strangulation

• Classification of Strangulation
• Hanging ( most common )
• Ligature strangulation
• Manual strangulation
• Postural strangulation

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Clinical Features

• Superficial Deep Neck
• Respiratory (delayed mortality)
• Bronchopneumonia
• Aspiration pneumonitis
• Delayed airway obstruction
• ARDS
• Neuro psychiatric

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Management

• Spinal cord injury is very rare
• Phenytoin useful in preventing ischemic cerebral
  damage
• Naloxone
• Ca2 channel blocker

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Summary

• Structured approach to these
• patients, regardless of
• mechanism is essential to
• optimize outcome avoid
• catastrophe