penetrating neck injury
TRANSCRIPT
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Department of surgery Songkhla hospital
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Superficial cervical fascia - platysma Deep cervical fascia
◦Investing : sternocleidomastoid muscle, trapezius muscle
◦Pretracheal : larynx, trachea, thyroid gland, pericardium
◦Prevertebral : prevertebral muscles, phrenic nerve, brachial plexus, axillary sheath
◦Carotid sheath : carotid artery, internal jugular vein, vagus nerve
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Wounds that penetrate the platysma must be further evaluated
The major vascular and aerodigestive structures in the neck are located in the anterior triangle, and all are deep to the platysma
Penetrating injuries to the posterior triangle should raise concern about trauma to the cervical spine and spinal cord
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Zone I is the thoracic inlet from the sternal notch to the cricoid cartilage
Zone II is the midportion of the neck from the cricoid cartilage to the angle of the mandible
Zone III extends from the angle of the mandible to the base of the skull
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Zone I◦ Contains the subclavian arteries and veins, the
dome of the pleura, esophagus, great vessels of the neck, recurrent nerve, trachea
Zone II◦ Contains the larynx, pharynx, base of tongue,
carotid artery and jugular vein, phrenic, vagus, and hypoglossal nerves
Zone III◦ Contains the internal and external carotid
arteries, the vertebral artery, and several cranial nerves
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Does the patient require emergent airway protection?
What is the best approach and technique for airway protection?
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Airway compromise (eg, respiratory distress, severe hemorrhage, extensive or sucking neck wound, shock)
Definite airway should be perform such as orotracheal tube or surgical airway
Surgical airway is recommended if significant trauma or obstruction above the larynx or if anatomy is sufficiently distorted and airway cannot be identified
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Significant bleeding or hematoma Hemoptysis Subcutaneous emphysema Bruit or thrill Neurologic deficit Distorted neck anatomy Stridor Difficulty or pain when swallowing secretion Abnormal voice especially hoarseness(hot
potato voice)
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Method Oral & nasal intubation with or without endoscopic
guidance or muscle relaxants Surgical airway
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Surgical airway◦Cricothyrotomy (life saving procedure ,
temporary airway) ◦Tracheostomy
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Zone I injuries with concomitant thoracic injuries◦pneumothorax◦hemopneumothorax◦tension pneumothorax
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Bleeding should be controlled by pressure Do not clamp blindly or probe the wound
depths The absence of visible hemorrhage does not
rule out Two large bore IVs
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Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits
Neuro exam: mental status, cranial nerves, and spinal column
Examine the chest, abdomen, and extremities
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Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here
Don’t blindly explore wound or clamp vessel
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Unstable patient Immediate transfer to the OR
Stable patient◦Mandatory exploration◦Selective approach
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Vascular injury ShockHematoma
Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck Laryngotracheal injury Subcutaneous emphysema
Airway obstruction Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia
Pharynx/esophagusinjurySubcutaneous emphysema Hematemesis Dysphagia or odynophagia
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X-Rays◦Pneumothorax or hemothorax◦retropharyngeal air or
pneumomediastinum, suggests esophageal injury
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CT neck◦A multidetector helical CT scan (MDCT) is often the first study obtained because it can detect laryngotracheal, vascular, and esophageal injuries simultaneously and rapidly
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Esophagography◦All penetrating neck injuries due to high incidence of occult esophageal injuries
Endoscopy◦If swallow (-), enhances sensitivity for penetrating esophageal injury
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CT-Angiogram◦The sensitivity and specificity of CT-A for
detecting significant vascular wounds in the neck approaches nearly that of standard angiography
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Angiography◦Angiography demonstrates sensitivity
and specificity of close to 100 percent and has been considered the gold standard in stable patients
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Endoscopy or laryngoscopy◦alternatives for the diagnosis of LT
trauma
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