Rivera, Rivere, Robosa, Rodas, Rodriguez, Rogelio, Roque, Ruanto
Neck Trauma Rivera, Rivere, Robosa, Rodas, Rodriguez, Rogelio, Roque, Ruanto brought to the UST ER 20 minutes after
25 year old male stabbed in the neck brought to the UST ER 20 minutes after stab wound at the right side of the neck at the level of the cricoid conscious, coherent, agitated; talks in phrases
Physical Exam conscious, coherent, agitated; talks in phrases Pale palpebral conjunctivae, anicteric sclerae VS : BP = 90/60 PR = 100/min RR = 25/min Airway is patent; no blood in the oral cavity Crepitation in the neck; continuous bleeding from the stab wound site Symmetrical chest expansion; equal breath sounds Abdomen soft, nontender Background Few emergencies pose as great a challenge as neck trauma.
Because a multitude of organ systems (eg, airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound is capable of considerable harm Anatomic zones Dividing the neck into anatomic zones or regions assists in the evaluation of injury. The sternocleidomastoid separates the neck into anterior and posterior triangles. Most of the important vascular and visceral organs lie within the anterior triangle bounded by the sternocleidomastoid posteriorly, the midline anteriorly, and the mandible superiorly. Anatomic Zones Zone I the base of the neck, is demarcated by the thoracic inlet inferiorly and the cricoid cartilage superiorly. Zone II encompasses the midportion of the neck and the region from the cricoid cartilage to the angle of the mandible. Zone III characterizes the superior aspect of the neck and is bounded by the angle of the mandible and the base of the skull. Structures at risk Zone I
great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, and jugular veins, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots Zone II carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, and cervical spine and spinal cord Zone III salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, and major nerves (including cranial nerves IX-XII) Penetrating Trauma Vascular injuries arising from penetrating trauma may occur directly, causing a partial or complete transection of the vessel or inducing formation of an intimal flap, arteriovenous fistula, or pseudoaneurysm. Thrombosis 25-40% Common sites: internal jugular vein (9%) carotid artery (7%) pharynx or the esophagus occurs in 5-15% larynx or the trachea 4-12% Major nerve injury occurs in 3-8% of patients sustaining penetrating neck trauma. Spinal cord injury occurs infrequently and almost always results from direct injury rather than secondary osseous instability. Blunt Trauma motor vehicle crashes sports-related injuries
clothesline tackle strangulation blows from the fists or feet excessive manipulation (ie, any manual operation such as chiropractic treatment or physical realignment or repositioning of the spine). Direct forces can shear the vasculature.
Excessive rotation and/or hyperextension of the cervical spine causes distention and stretching of the arteries and veins producing shearing damage and resultant thrombosis. Intraoral trauma may extend to the cerebral blood supply. Basilar skull fractures may disrupt the intrapetrous portion of the carotid artery. Impact to the exposed anterior aspect of the neck may crush the larynx or the trachea, particularly at the cricoid ring, and compress the esophagus against the posterior spinal column. A sudden increase in intratracheal pressure against a closed glottis (eg, improper wearing of a seat belt), a crush bruise (eg, clothesline tackle), or a rapid acceleration-deceleration action may cause a tracheal injury. Resuscitation in the ER
Assessment of Severity of the Injury Definitive Therapy Neck Injury Zones I, II, III
Zone I angle of mandible to base of skull Zone II cricoid cartilage to angle of mandible Important structures in this region include the carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, and cervical spine and spinal cord. Zone II injuries are likely to be the most apparent on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with zone II injuries Zone III (thoracic inlet) - sternal notch to cricoid cartilage Townsend: Sabiston Textbook of Surgery, 18th ed. Approach to the unstable patient Airway Early orotracheal intubation Oxygenation Breathing Check for concomitant injuries or presence of pneumothorax Circulation Digital control of the bleeding
IV access and judicious fluid resuscitation 1L IV bolus of normal saline, Ringers lactate or other isotonic crystalloid solution Packed red blood cell Disability Check for neurologic signs Exposure Check for other wounds Operation Prompt wound exploration Resuscitation in the ER
Assessment of Severity of the Injury Definitive Therapy Clinical Indications for Neck Exploration
Vascular Expanding hematoma External hemorrhage Diminished carotid pulse Airway Stridor Hoarseness Dysphonia / voice change Hemoptysis Subcutaneous air Digestive Tract Dysphagia / odynophagia Subcutaneous air Blood in oropharynx Neurologic Lateralized neurologic deficit consistent with injury Altered state of consciousness not caused by head injury conscious, coherent, agitated; talks in phrases; VS: BP = 90/60 PR = 100/min RR = 25/min Townsend: Sabiston Textbook of Surgery, 18th ed. Penetrating Neck Trauma Algorithm Algorithm for the selective management of penetrating neck injuries
Penetrating Neck Injury Unstable Stable Symptomatic Asymptomatic Angio Testing Esophageal w/u Observe Neck Exploration Immediate Zone I Zone II Zone III Zone II/III Penetrating injury in Zone II for Neck Exploration
Preoperative workup in this subset of patients is minimal. Patients with penetrating injuries in zone II are generally taken directly to surgery Patients with injuries in zone I and zone III should undergo preoperative radiographic vascular imaging, if possible. Preoperative workup in this subset of patients is minimal. Patients with penetrating injuries in zone II are generally taken directly to surgery, whereas patients with injuries in zone I and zone III should undergo preoperative radiographic vascular imaging, if possible. Workup of the aerodigestive tract is undertaken at the time of surgical exploration. Neck injuries not requiring operative exploration may need to have the aerodigestive tract evaluated with CT, bronchoscopy, upper endoscopy, or esophagography to exclude injury. Townsend: Sabiston Textbook of Surgery, 18th ed. Penetrating Injury in Zone II, stable asymptomatic
Optimal approach controversial: Mandatory surgical exploration for all penetrating injuries because of a low rate of complications and the potentially devastating effect of delay in the diagnosis of aerodigestive tract injuries. Selective exploration based either on the results of extensive evaluation, including angiography, esophagoscopy, and esophagography, or on progression of clinical symptoms. Work-ups are usually done on patients with: Neck injury in zone II, stable and asymptomatic Neck injury in zones I and III Blunt neck trauma Work-ups:CT scan is advocated Townsend: Sabiston Textbook of Surgery, 18th ed. Work-ups Some centers advocate thin-slice CT scanning of the neck with IV contrast to determine the track of a penetrating object, such as a knife or gunshot wound. Knowledge of the trajectory of penetration permits determination of anatomic structures at risk for injury. The presence of contrast extravasation or nonvisualization of vascular structures, or free air in the tissue planes, suggests tissue injury. Thin-slice CT scanning may also provide information about injuries to the cervical spine and aerodigestive tract. We favor an aggressive CT imaging approach to asymptomatic zone II injuries. Patients with zone I and zone III injuries who are asymptomatic should also undergo CT imaging and be observed if this study is negative. Townsend: Sabiston Textbook of Surgery, 18th ed. Surgical Neck Exploration
Neck exploration should be performed in the operating room under general endotracheal anesthesia Hemodynamically stable patient with a patent airway intubation can be deferred until laryngoscopy and bronchoscopy have been performed Nasogastric tube is passed to ensure an empty stomach Chest auscultation Neck Exploration Incisions Resuscitation in the ER
Assessment of Severity of the Injury Definitive Therapy Management of Specific Injuries
Blood vessels most commonly injured Hemostasis should be maintained by direct pressure or digital occlusion until proximal and distal control of vessel is achieved Choice of graft material should be based on size Polytetrafluorethylene is commonly used Management of Specific Injuries: Airway Injuries
Signs of larynx or trachea injury: Voice alteration Hemoptysis Stridor Drooling Sucking, hissing, or air frothing or bubbling through the neck Subcutaneous emphysema and/or crepitus Hoarseness Dyspnea Distortion of the normal anatomic appearance (eg, loss of normal landmarks, asymmetry, flattened thyroid prominence, tracheal deviation) Pain on palpation or with coughing or swallowing Pain with tongue movement implies injury to the epiglottis, hyoid bone, or laryngeal cartilage Crepitus (This hallmark sign of disruption to aerodigestive tract is noteworthy in only one third of cases.) Airway Injuries Penetrating injuries to the airway
either clinically overt, with bubbling and air movement through the wound, or found at the time of neck exploration performed for other indications. Blunt laryngotracheal injuries the diagnosis is generally established through a combination of neck CT, direct laryngoscopy, and bronchoscopy. The need for operative intervention for laryngeal trauma is determined by the degree of anatomic derangement and mucosal integrity in the larynx. Male with tracheal laceration from masonery saw. ETT inserted through wound. Nil great vessel damage. Required tracheostomy. Airway Injuries Lacerations are dbrided and closed primarily
Simple lacerations of the trachea repaired by direct suture If there is significant tissue loss, the trachea can usually be mobilized sufficiently to allow for the loss of about two tracheal rings without undue difficulty. Loss of a larger portion of trachea may necessitate tracheostomy or complex reconstructive procedures. Laryngeal injuries treated by closure of mucosal lacerations and reduction of cartilaginous fractures careful anatomic reconstruction, if possible, is critical difficult to treat Management of Specific Injuries: Pharynx and Esophagus
If the diagnosis is made early primary surgical repair is generally possible. If the diagnosis is delayed for > 12 hours primary repair may be impractical diversion and drainage being the only alternative The major morbidity and mortality associated with esophageal injuries are the result of delay in diagnosis Signs of esophagus and pharynx injury
Pharynx and Esophagus Signs of esophagus and pharynx injury Dysphagia Bloody saliva Sucking neck wound Bloody nasogastric aspirate Pain and tenderness in the neck Resistance of neck with passive motion testing Crepitus Bleeding from the mouth or nasogastric tube The basic approach to esophageal injuries:
The esophagus must be sufficiently mobilized to allow full evaluation of the wound and careful dbridement of devitalized tissue. The injury should be repaired primarily if possible, either by a one-layer or two-layer technique. If the tissue loss is sufficient to preclude primary repair, cervical esophagostomy should be performed as a temporizing measure, with plans for complex reconstruction of the esophagus after the initial trauma has resolved. A drain should be left in place after all esophageal repairs. Diagnostic Procedures
Radiography Upper and mid esophageal perforations The most frequent site of these perforations is at the level of the cricopharyngeus muscle,and most perforations are iatrogenic. The conventional radiographic findings include widening of the precervical soft tissues, air in the precervical soft tissues, widening of the superior mediastinum, and a right-sided hydrothorax. Water-soluble contrast study of the upper esophagus shows leakage of contrast material after instrumentation. Cervical abscess following esophageal injury subsequent to endotracheal intubation. Note the increased soft tissue prevertebral space and air in the soft tissues Diagnostic Procedures
Computed Tomography CT findings in esophageal tear/perforation: Extraluminal air in the mediastinum or surrounding the esophagus is the most reliable sign and, when taken in conjunction with the clinical presentation, has a 92% accuracy. Gas may appear as a single or multiple discrete collections, particularly with mediastinal abscess formation. Air fluid levels may also be seen within mediastinal abscesses. Other findings include obliteration of fat planes in the mediastinumresulting frominflammation, periesophageal/mediastinal fluid, esophageal thickening, pleural effusions (usually unilateral), extravasation of oral contrast material into the periesophageal tissues, and a tract at the site of the tear Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow). Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows leakage of oral contrast material (blue arrow) and air in the posterior mediastinum (red arrow). Diagnostic Procedures
Ultrasonography Ultrasonography has not been used in the diagnosis of esophageal tears and perforations; however, transesophageal endosonography has been used to evaluate posterior mediastinitis, which is a known complication of esophageal tears DIAGNOSIS JOURNAL Objective To assess the impact of the increasing use of MDCT angiography in the setting of blunt and penetrating neck trauma on the use of digital subtraction angiography (DSA) Background of the Study
Although digital subtraction angiography (DSA) is still accepted as the gold standard for imaging the major vessels of the neck, the reported high number of patients with negative results and the risk associated with performing such procedures have prompted a search for other less invasive imaging techniques. Noninvasive techniques that have been explored as a potential replacement for catheter angiography in this patient population include MR angiography, duplex sonography, and CT angiography. Background of the Study
In recent years, CT angiography has also been reported to be useful in the detection of injuries to the major arteries. Prior studies using single-detector helical CT have shown high sensitivity and specificity for detecting injuries to major vessels of the neck in the setting of both blunt and penetrating trauma. Patient Population In general, the patient is considered to be at risk for having an arterial injury and a candidate for diagnostic angiography if one or more of the following signs or symptoms are present: active bleeding from an unknown source stable or expanding neck hematoma neck pain with focal neurologic deficit palpable bruit or thrill Methodology Retrospective: 36 months (Jan 2001 Dec 2003)
January 2001 to December 2003, 57 patients were referred for CT angiography or DSA of the neck after blunt or penetrating neck trauma All CT angiograms were acquired with a 4-MDCT scanner The patients were divided into three groups on the basis of consecutive 12-month periods (2001, 2002, and 2003), and the initial imaging technique was recorded The results of CT and digital subtraction angiograms were compared with operative findings and with clinical course, when available. Methodology Of the 57 patients, 17 underwent both MDCT angiography and DSA during the study period. The mean age of the study population was 31 years with an age range of 1490 years. The mechanism of injury in the study population included gunshot wound (n=21), stab wound (n=12), motor vehicle crash (n=12), assault with a blunt object (n=4), attempted hanging (n=2), fall (n=3), crush injury (n=1), and twisting injury (n=2). Methodology CT angiography examinations were reported as positive when one or more of the following findings were present: arterial dissection, arterial pseudoaneurysm, arterial transection, or arterial occlusion. Findings were reported as indeterminate if isolated IV contrast extravasation was present without an identifiable arterial injury on the CT images Results In 2001, 12 patients were referred for imaging: nine patients were evaluated initially with DSA and three patients were evaluated with CT angiography and subsequently with DSA for further evaluation. In two of these three patients, CT angiograms showed no abnormality and this result was confirmed with catheter angiography The third patient underwent DSA for suspected pseudoaneurysm of the superior thyroidal branch of the external carotid artery based on findings present on the initial CT angiography; DSA confirmed this finding Results In 2002 and 2003, 11 and 34 patients, respectively, underwent CT angiography as the initial imaging examination. During these 2 years, no patient underwent DSA as the initial diagnostic test, but five patients underwent DSA after CT angiography for the following indications: evaluation of nondiagnostic CT angiograms (n=1) confirmation of findings when requested by the clinical service (n=2) and catheter-guided therapy (n=2) Results 2002 Of the 11 CT angiography examinations, one patient with a gunshot wound to the neck was found to have an occlusion of the left internal carotid artery and dissection of the left vertebral artery Another patient with a large laceration from a stab wound had negative findings on the initial CT angiogram. This patient was taken to the operating room for wound exploration before repair of the laceration, and a facial vein laceration was repaired Nine other patients with negative CT angiography findings were managed conservatively, without further intervention or diagnostic imaging Results 2003 Of the 33 diagnostic CT angiograms, five were reported as positive for arterial injury. pseudoaneurysm and dissection (n=1), pseudoaneurysm and occlusion (n=1), iso- lated pseudoaneurysm (n=1), isolated occlu- sion (n=1), and pseudoaneurysm with occlu- sion and active extravasation (n=1) Isolated contrast extravasation was reported as indeterminate for arterial injury in three patients In one patient, a right common carotid artery pseudoaneurysm was identified on initial CT angiography, and catheter angiography was requested. On confirmation of the findings, the patient underwent operative repair. Results 2003 In the remaining 25 patients in whom the initial CT angiography findings were considered negative, two patients were explored surgically despite negative CT angiography findings because of a high clinical suspicion for vascular injury based on the mechanism of injury in both cases, no vascular injury was identified Three other patients were subsequently imaged using MR angiography of the head and neck for evaluation of suspected intracerebral vascular pathology as a cause for persistent neurologic systems all MR angiograms were interpreted as negative. Summary of Results During the 3-year period of this retrospective study, eight (14%) of 57 patients in the study population had vascular injuries. When CT angiography was performed as the initial im- aging examination, seven (15%) of 48 patients had cervical arterial injuries. Discussion DSA is the generally accepted gold standard for evaluating the major vessels of the neck and, until recently, has also served as the initial imaging examination requested by trauma and vascular surgeons when such injuries are suspected However, the small but appreciable risks associated with DSA, the extended procedure time, and the additional staff required to perform this procedure have led to a search for other potential imaging diagnostic techniques Discussion Unlike MR angiography, CT angiography is generally available in most emergency radiology departments and can be performed at the time of diagnostic imaging for other organ systems in the patient with multiple injuries from trauma. Even when MR angiography is available immediately, the time needed for the examination may be prohibitive even in hemodynamically stable patients. In addition, flow effects, artifacts, and limited spatial resolution compared with CT may limit the sensitivity of MR angiography for detecting clinically significant injuries. CT angiography offers advantages over color Doppler sonoraphy including lack of operator dependence and ability to image patients with difficult anatomy or with neck hematomas that are not easily amenable to sonographic scanning Conclusion The advent of MDCT allows improved spatial resolution, and the diagnostic potential of CT angiography in the acute trauma patient will undoubtedly increase with the introduction of CT scanners with more than 16 detector rows CT angiography has essentially replaced DSA as the study of choice for the initial evaluation of the neck vessels in the setting of blunt or penetrating trauma. Only a minority of patients will require DSA after CT angiography for therapeutic interventions or for further diagnostic investigation when initial results are equivocal or nondiagnostic. CT angiography allows appropriate triage of patients to conventional angiography or surgery for appropriate treatment and can guide conservative management when appropriate. John M. Tallon, MD;* Jennifer M. Ahmed, MA; Beth Sealy, BA
TREATMENT JOURNAL Airway management in penetrating neck trauma at a Canadian tertiary trauma centre John M. Tallon, MD;*Jennifer M. Ahmed, MA;Beth Sealy, BA From the*Departments of Emergency Medicine and Surgery, Dalhousie University, Halifax, NS, theNova Scotia Trauma Program, Halifax, NS and theFaculty of Medicine, Dalhousie University, Halifax, NS. CJEM2007;9(2): Objectives:The optimal approach to airway management in penetrating neck injuries (PNIs) remains controversial. The primary objective of this study was to review the method of endotracheal intubation in PNI at a Canadian tertiary trauma centre. Secondarily, we sought to determine the incidence of PNI in our trauma population and to describe the epidemiologic elements of this population. Methods:We conducted a review of patients with PNIs who were enrolled in the Nova Scotia Trauma Registry database. We included all penetrating injuries of the neck in patients 16 years of age from April 1, 1994 to March with an Injury severity Score (ISS) 9 or who underwent Trauma Team activation at our Tertiary Trauma Centre (regardless of ISS) and/or who were identified upon admission as a "major" trauma case. The variables of interest were patient age and sex, injury mechanism, injury location, place of intubation and method of intubation. Results: There were 19 people who met inclusion criteria and they were enrolled in our study. The injury mechanisms involved knife (n = 13) or gunshot (n = 5) wounds (one patient's injuries were categorized as "other"). Three patients (15.8%) were not intubated. The remaining 16 patients were intubated during prehospital care (n = 5), in the emergency department (n = 6) or in the operating room (n = 5). Of these, 8 patients (42.1%) underwent awake intubation and 8 (42.1%) underwent rapid sequence intubation. Conclusion: There is clear variability of airway management in PNI. We believe that such patients represent a heterogeneous group where the attending physician must have a conservative yet varied approach to airway management based on the individual clinical scenario.