Penetrating Neck Trauma

1
Penetrating Neck Trauma

• Umut Sarpel
• PGY-4

2
Case Presentation

• 31M
• No PMHx
• Single GSW to neck
• Handgun at 15 ft range

3
Case Presentation

• Hemodynamically stable
• 130/75, 86, 18, 99 on NC
• Spontaneous, regular respirations

4
Exam

• 0.5 cm entry wound at midline in Zone I
• No exit wound
• Small hematoma, no active bleeding
• No crepitus
• Breath sounds b/l
• 2 pulses b/l UE
• 4/4 strength, sensation b/l
• CN II-XII grossly intact

5
Management

• Labs - Hct 44
• otherwise unremarkable
• CXR obtained

6
(No Transcript)
7
Management

• CXR R hemothorax
• R chest tube ? 500 cc blood
• Flexible laryngoscopy ? no obvious injury
• Airway control ? fiberoptic awake nasotracheal
  intubation by anesthesia

8
Management

• Angiogram obtained

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
Operative Course

• Median sternotomy
• Pseudoaneurysm of brachiocephalic artery
• Proximal/distal control
• Interposition graft with PTFE from
  brachiocephalic to subclavian artery

14
Operative Course

• Injury to brachiocephalic vein noted controlled
  and ligated
• Neck dissection ? no tracheal injury
• Rigid esophagoscopy ? no injury noted

15
Post-Op Course

• Post-op head CT no infarct
• SICU ventilatory support
• Moderate output from chest tube
• 2U PRBC on POD3
• Neurologically intact
• Progressive vent weaning

16
Overview

• Complex anatomy, many organ systems,
• each requiring evaluation
• Vascular
• Respiratory
• Digestive
• Neurologic
• Endocrine
• Skeletal

17
(No Transcript)
18
Overview

• Anatomy
• Signs / symptoms of injury
• Evaluation
• Management

19
Anatomy Zones
20
Anatomy Zones
Zone III
Zone II
Zone I
21
Signs Vascular Injury

• Shock
• Hemorrhage
• Hematoma
• Evolving stroke
• Pulse differential in upper extremities
• Bruit or thrill

22
Signs Laryngotracheal Injury

• Subcutaneous emphysema
• Sucking wound
• Hemoptysis
• Dyspnea
• Stridor
• Hoarseness or dysphonia

23
Signs Esophageal Injury

• Often clinically silent
• Milder subcutaneous emphysema
• Bloody saliva
• Dysphagia or odynophagia
• Fever (late)

24
Signs Spinal Injury

• Neurologic defect
• Spinal shock
• Hypotensive, often not tachycardic
• (But in a hypotensive trauma pt,
• always assume hemorrhagic shock first)

25
Mechanism

• Stab wound
• What you see is what you get
• GSW
• Unpredictable trajectory
• Thermal injury
• Maintain high level of suspicion

26
(No Transcript)
27
Evaluation

• Old standard formal neck exploration for all
  penetrating trauma that violates platysma
• Was a/w 50 negative exploratory rate
• New focus on directed exams angiography,
  esophagoscopy, esophagography, laryngoscopy

28
Management Vascular Injuries

• Zone II vascular injuries readily apparent
• Zone I and III injuries more difficult to detect
  due to anatomical constraints
• 32 of pts w/ major Zone I vascular injury had
• no localizing PE findings

29
Management Vascular Injuries

• Angiography adjunctive diagnostic tool
• Arteriogram can also be therapeutic w/
  embolization (works esp well in Zone III where
  vessels are smaller)
• Duplex exam
• in qualified centers may be acceptable
• alternative

30
Management Vascular Injuries

• In general, vessels should be repaired rather
  than ligated
• Carotid injuries should be repaired unless there
  is an already established dense neurologic
  deficit w/ edema (revascularization may convert
  ischemic to hemorrhagic infarct)
• If bypass is needed, PTFE preferred over
  saphenous vein graft

31
(No Transcript)
32
Management Esophageal Injury

• Early detection of injury is paramount
• If repaired lt 24hrs, survival 90
• If gt 24 hours, survival 64
• Best detected by combination of esophagoscopy and
  esophagography (sensitivity near 100)
• Rigid / flexible endoscopy both acceptable

33
Management Esophageal Injury

• Operative repair
• Primary closure is ideal (esp lt 24 hrs)
• Close over a T-tube
• Buttress w/ muscle flaps or pleura
• Divert with esophageal stoma
• Widely drain
• Fistula rate up to 57
• Consider routine swallow studies

34
Management Tracheal Injury

• Thorough laryngoscopy
• Primary repair is the rule, tracheal mobility
  allows closure of defects up to 2-3cm
• Tracheotomy rarely indicated, only for a large
  defect (increases risk of infection)
• Absorbable suture

35
Management Spinal Injury

• Can only prevent further injury
• Steroids
• appear to have some benefit in blunt
• trauma, but no evidence for routine use
• in penetrating trauma

36
Algorithm
37
Conclusions

• Know your anatomy
• Neck exploration is no longer mandatory in
  asymptomatic pts
• Physical exam is probably the most useful
  diagnostic tool (esp Zone II)
• Non-invasive diagnostic / therapeutic modalities
  should be utilized