A CASE PRESENTATION AND DISCUSSION ON HEAD AND NECK TRAUMA
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1 A CASE PRESENTATION AND DISCUSSION ON HEAD AND NECK TRAUMA Nolan Ortega Aludino, M.D. Department of Surgery Ospital ng Maynila Medical Center
2 General Data: B.R. 64 year old Male Tondo Manila
3 Chief Complaint: Stab wound
4 History of Present Illness 30 minutes PTC patient was involved in a brawl and was allegedly stabbed in the neck Consult at the E.R.: hematemesis
5 Physical Examination General Survey: Conscious, coherent, in distress Vital Signs BP = 80/50 CR = 97 RR = 24
6 Physical Examination Stab wound Approx. 2 cms Lateral Neck, Left (+) air bubbling
7 Physical Examination Chest: Symmetrical chest expansion, no retractions, clear breath sounds Cardiac: Normal rate, regualr rhythm, murmur
8 Physical Examination Abdomen: Flat, soft, nontender, no mass Extremities: Full and equal pulses, no deformities
9 Salient Features 64 y/o Male Stabwound, neck Hypotension Air bubbling Hematemesis
10 STAB WOUND, NECK PENETRATING NECK INJURY NON PENETRATING NECK INJURY
11 STAB WOUND, NECK PENETRATING NECK INJURY NON PENETRATING NECK INJURY (+) AIR BUBBLING THROUGH WOUND
12 PENETRATING NECK INJURY VASCULAR TRACHEA ESOPHAGUS VERTEBRA SPINAL CORD THYROID
13 PENETRATING NECK INJURY VASCULAR (+) HYPOTENSION
14 PENETRATING NECK INJURY TRACHEA (+) AIR BUBBLING THROUGH THE WOUND
15 PENETRATING NECK INJURY ESOPHAGUS (-) subcutaneous emphysema (-) pain on swallowing (+) hematemesis proximity to the trajectory of the wound
16 PENETRATING NECK INJURY (-) sensory and motor deficit below the injury VERTEBRA SPINAL CORD
17 PENETRATING NECK INJURY Proximity of the gland to the SW THYROID
18 Pre Treatment Diagnosis Primary Secondary Diagnosis PENETRATING NECK INJURY ZONE 2 SECONDARY TO STABWOUND WITH PROBABLE TRACHEAL INJURY and VASCULAR INJURY PENETRATING NECK INJURY ZONE 2 SECONDARY TO STABWOUND WITH PROBABLE TRACHEAL INJURY without VASCULAR INJURY Certainty 90% 10%
19 Paraclinical Diagnostic Procedure Do I need to perform a paraclinical diagnostic procedure? NO Certain of diagnosis Unstable patient
20 GOALS OF TREATMENT Resolve bleeding Resolve air leak
21 TREATMENT OPTIONS
22 PRE OPERATIVE PREPARATION Informed consent for immediate operation Psychosocial support Optimize patient s condition Screen for any condition that will interfere with treatment Prepare OR materials/blood Preoperative antibiotics started
23 INTRAOPERATIVE MANAGEMENT Patient supine under GETA Asepsis and antisepsis Sterile drapes placed Incision done over the anterior edge of the left sternoclaedomastoid muscle Skin flaps created SCM retracted laterally Strap muscles over stab wound transected
24 Intra operative findings: INTRAOPERATIVE 2 cm perforation at the left laryngopharyngeal area just above the thyroid cartilage, near the epiglottis venous bleeder 3mm beneath the strap muscles MANAGEMENT
25 INTRAOPERATIVE MANAGEMENT BENEFIT RISK COST AVAILABILITY Primary repair without Tracheostomy Controls air leak with no stoma High success rate for non complicated injury Anastomotic leak Airway obstruction + Available Primary repair with Tracheostomy Controls air leak Assures airway patency and good mucus clearance postoperatively Risk associated with tracheostomy and tracheostomy care + * Additional cost of the tracheostomy set Available
26 INTRAOPERATIVE MANAGEMENT Primary repair done Hemostasis Correct sponge and instrument count Layer by layer closure with placement of drain DSD
27 Operation Done Neck exploration Primary repair, laryngopharyngeal injury Ligation of bleeder
28 POST OPERATIVE MANAGEMENT DAT when fully awake Adequate analgesia» Mefenamic Acid 500 mg/tab 1 tab every 8 hours for pain in full stomach Adequate hydration Early ambulation Daily wound care 1 st POD- 2 nd POD- Follow-up on out-patient basis after 1 week To come back any time if with problems regarding the operation
29 FINAL DIAGNOSIS PENETRATING NECK INJURY ZONE 2 SECONDARY TO STABWOUND WITH LARYNGOPHARYNGEAL INJURY
30 PREVENTION AND HEALTH PROMOTION Advise given to patient regarding Possible complications Proper wound care OPD follow up
31 DISCUSSION
32 ETIOLOGY missile injuries from firearms stab injuries Blast injuries with penetrating bomb and mortar fragments (less common) Accidental (falls on sharp objects) Motor vehicle accidents
33 Zones of the Neck: ZONE I from cricoid cartilage to the clavicle ZONE II from angle of the mandible to the cricoid cartilage ZONE III above the angle of the mandible to the base of the skull
34 Zone 1 includes the thoracic inlet subclavian artery and vein jugular vein common carotid artery Esophagus Thyroid trachea.
35 Zone 2 common carotid artery internal and external carotid arteries jugular vein Larynx Hypopharynx cranial nerves X, XI, and XII.
36 Zone 3 internal and external carotid arteries jugular vein lateral pharynx cranial nerves VII, IX, X, XI, XII.
37
38 Complications Bleeding Mediastinitis (most significant acute) Infection Nerve injury (may present late) Formation of fistula
39 current mortality rate for penetrating neck injury is 3-6%, 50% of deaths caused by vascular injuries cause complications in 40% of cases 10% of patients: injury to the carotid artery Aerodigestive tract injuries: 23-30% Esophageal injuries associated with mortality rates of 11-17%.
40 References Brett Siegrist, MD, and Glen Steeb, MD, Trauma Program, Charity Hospital of Louisiana, New Orleans, La Penetrating Neck Injuries South Med J 93(6):, Snyder MC, Lidiatt, W; Penetrating Neck Injuries emedicine H.J.Hammawa, S.G. Marshall, E.Ghareeb and W. Holmes, Unusual Penetrating Metal Fragment Injury ti the Neck Hersam G, Barker P, Bowley DM, Boffard KD. The management of penetrating Neck injuries. Int Surg 2001 Apr-Jun;86(2). LeBoeuf H.J.; Penetrating Neck Trauma, Dept. of Otolaryngology, UTMB, Grand Rounds Presentation 1999
41 Questions MCQ #1 The current mortality rate for penetrating neck injury is. a. 1-2% b. 3-6% c. 7-10% d %
42 Questions MCQ #1 The current mortality rate for penetrating neck injury is. a. 1-2% b. 3-6% c. 7-10% d %
43 Questions MCQ #2 The most significant acute complication that the clinician should watch out for in cases of penetrating neck injuries is: a. Mediastinitis b. Bleeding c. Infection d. Wound dehiscence
44 Questions MCQ #2 The most significant acute complication that the clinician should watch out for in cases of penetrating neck injuries is: a. Mediastinitis b. Bleeding c. Infection d. Wound dehiscence
45 Questions MCR #3 (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) Zone 3 of the neck contains the following structures: 1. Internal and external carotid arteries 2. Jugular vein 3. Lateral pharynx 4. Cranial nerves VII, IX, X, XI, XII.
46 Questions MCR #3 (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) Zone 3 of the neck contains the following structures: 1. Internal and external carotid arteries 2. Jugular vein 3. Lateral pharynx 4. Cranial nerves VII, IX, X, XI, XII.
47 Questions MCR #4 (a = 1,2,3; b = 1,3; c = 2,4;d = 4 only; e = all) The indications for exploration of a penetrating neck injury include: 1. Unstable patient 2. Zone 1, symptomatic patient 3. Zone 2, symptomatic patient 4. Zone 3, symptomatic patient
48 Questions MCR #4 (a = 1,2,3; b = 1,3; c = 2,4;d = 4 only; e = all) The indications for exploration of a penetrating neck injury include: 1. Unstable patient 2. Zone 1, symptomatic patient 3. Zone 2, symptomatic patient 4. Zone 3, symptomatic patient
49 Questions MCR #5 (a = 1,2,3; b = 1,3; c = 2,4;d = 4 only; e = all) The most common causes of penetrating neck injuries are: 1. Firearms 2. Motor vehicle accidents 3. Stab 4. shrapnels
50 Questions MCR #5 (a = 1,2,3; b = 1,3; c = 2,4;d = 4 only; e = all) The most common causes of penetrating neck injuries are: 1. Firearms 2. Motor vehicle accidents 3. Stab 4. shrapnels
51
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