Trauma

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Trauma
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The incidence of blunt trauma to the neck is
reduced in US due to seat belt
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The anterior neck is shielded by the anterior
mandible and the clavicle .
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When blunt trauma to the does occur , the
laryngotracheal tree is the most vulnerable to
injury
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Major vessels injury due to blunt trauma is an
extermaly rare phenomenon .
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It must be considered if the patient has
expanding hematoma carotid bruit , or neurologic
finding .
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Emphysema , dysphagia , odynophagia

• Perforation or tear of
• pharynx
• hypopharynx
  
• esophagus

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Penetrating trauma
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• Stab wound , Gun injury
• M/F 5/1
• Most injuries occur in the anterior neck
• Type of injury depend on the type of object and
  the area of the neck that is injured .

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Anatomic classification
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The platysma , which extends from the facial
muscles to the calvicle , remains the key
anatomic land mark when dealing with penetrating
neck trauma
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Neck Zones
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Zone I

• Is the area of the neck between the clavicle and
  the cricoid cartilage
• It contains proximal common carotid , vertebral
  artery , subclavian artery , upper mediastinal
  vasculature , lung apices , trachea , esophagus ,
  thoracic duct

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It is difficult to gain emergent proximal control
of hemorrhage and it is difficult to expose
intrathoracic neurovascular structure
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Zone II

• Extending between cricoid cartilage and the angle
  of the mandible
• Containing carotid bifurcation , vertebral artery
  , IJV , larynx , trachea , esophagus , vagus ,
  RLN , spinal cord

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Zone III

• Is from the angle of the mandible to the base of
  the skull
• contains distal ECA branches , vertebral artery
  , salivary glands , pharynx , spinal cord , CN
  VII , VIII , IX , X , XII

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It is difficult to gain emergent distal control
of hemorrhage and it is difficult to expose skull
base neurovascular structures
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Evaluation
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Airway assessment

• Early airway intervention in the emergency room
  is paramount , especially in the face of an
  expanding hematoma
• A quick survey of the patient? s airway status
  must be made .
• A cricothyrotomy or vertical tracheotomy is the
  preferred of choice compared to oral or nasal
  intubation

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Endotracheal intubation may be considered in
select situation , but it may further exacerbate
bleeding , pharyngeal perforation , or
laryngotracheal injury
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One must assume a cervical spine injury until
further testing can be done . This is especially
important whenever one is establishing a surgical
airway .
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Circulation

• Any frank bleeding must be controlled with direct
  pressure only .
• Any use of clamping instrument should be
  condemned .
• Establishment large bore IV access

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Immediate surgical management

• Life-threatening hemorrhage
• Hemodynamic instability
• Expanding hematoma

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The operating room is the only place where a
wound is explored or probed or a foreign body is
removed .
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Secondary survey and definitive management can be
dine in a system by system fashion once the
airway has been addressed and the patient is
hemodaynamically stable .
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Respiratory tract injury

• 10 penetrating trauma
• Oropharynx .lung apices
• Cyanosis
• Air per wound
• Subcutaneous emphysema
• Hemoptysis
• Dysphonia
• Hoarseness
• Decreased breath sound

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An initial respiratory tract injury may appear
stable but may rapidly decompensate , requiring
emergent surgical airway intervention
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Vascular Injury

• Can be present in 25 penetrating trauma
• Inspection , palpation auscultation of the HN
  , upper extremity and thorax is important
• Hypovolumic shock , frank brisk bleeding ,
  expanding hematoma , decreased breath sound ,
  decreased radial pulse , carotid bruit

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Digestive tract injury

• In 5 penetrating trauma
• Most frequent missed injury
• Dysphagia , odynophagia , hematemesis , crepitus
  , free air on imaging
• Early intervention to exteriorize the leak to
  prevent mediastinitis

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Nervous system

• Complete or incomplete spinal cord transection
  should be considered localizing lateralizing
  deficit
• CN , brachial plexus , phrenic nerve
• Hemiplagia due to carotid or vertebral
  interruption

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Soft tissue injury

• Glandular or duct injury
• Saliva existing in the wound , associated
  facial or hypoglossal injury
• Left sided trauma in zone III thoracic duct
  injury

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MANAGEMENT
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Zone I

• Symptomatic
• Arteriography with or without esophageal
  study
• Asymptomatic
• Arteriography with or without esophageal
  study

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ZONE II

• Symptomatic
• To operating room if
  hemoptysis , dysphsgia , or nerve deficit is
  present
• Asymptomatic
• Observe

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Surgical exploration of zone II still remains an
area of great controversy
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ZONE III

• Symptomatic
• Arteriography with or without mbolization
• Asymptomatic
• With or without arteriography for possible
  occult vascular injury ( all patients admitted
  for overnight observation )

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Diagnostic imaging

• They will give important information and allow
  the surgeon to manage the patient in a more
  selective fashion

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• Arteriography in zone I , III
• Esophagography ( 90 sensitivity )
• CT ( laryngotracheal complex )
• Flexible laryngoscopy in awake patient and stable
  patient

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All attempts should be made to clear the cervical
spine prior to any operative manipulation
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• Awake tracheostomy ? Rigid endoscopic evaluation
• Parenteral antibiotic
• Tetanus toxoid booster

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• Occult vascular injury in zone III may often be
  managed with endovascular embolization but on
  rare occasion a lateral swing mandibulotomy may
  be required for surgical repair .

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Zone II vascular injuries can be directly
accessed via a transcervical approach .
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Vascular injury

• Simple laceration of IJV carotid ? primary
  repair
• Large damage ? ligation or saphenous vein
  interposition
• Zone I injury sternotomy ot thoracotomy

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All arterial vessels should be repaired , and
venous injuries can be ligated
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Pharyngoesophageal injuries

• Explored , debrided and closed primerily in one
  or two layer
• Drained with either a closed suction or a
  Penrose drain
• Direct insertion a NGT
• Late diagnosis (12h) drained wound

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Laryngotracheal injury

• Unstable patient tracheostomy
• Stable patient flexible laryngoscopy CT
• Inspection of carotid sheath , esophagus
  cartilaginous frame work
• Repair of endolarynx laryngofissure Thyroid
  cartilage fracture reapproximate suturing
• Tracheal laceration can be sutured or used for
  the tracheostomy site