Penetrating Neck Injuries. Jason Levine MD Lutheran Medical Center July 22, 2010
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1 Penetrating Neck Injuries Jason Levine MD Lutheran Medical Center July 22, 2010
2 CASE PRESENTATION 19 YO M 3 Stab Wounds Right zone I neck SW 2 SW anterior abdomen Left epigastrium anterior axillary line 2cm superior to left ASIS
3 CASE PRESENTATION On arrival NO airway compromise Normal breath sounds bilaterally VSS NO hard signs of vascular injury NO neurologic disability Had involuntary guarding and rebound tenderness on abdominal exam
4 INITIAL CHEST XRAY
5 OPERATIVE FINDINGS Prepared sterile field from chin to midthigh Midline laparotomy Approximately 100cc gross blood Left diaphragmatic injury 2 figure of prolene Distal transverse colon injury silk lembert repair
6 POST OPERATIVELY No major events Chest X ray performed in PACU CTA chest performed
7 POST OP CHEST XRAY
8 CT ANGIOGRAM CHEST
9 CT ANGIOGRAM IMPRESSION Extravasation of intravenous contrast Appears to be fistula between the SVC and aortic arch Patient continues to remain hemodynamically stable Interventional Radiology consulted for angiogram
10 ANGIOGRAM downstatesurgery.org
11 ANGIOGRAM downstatesurgery.org
12 ANGIOGRAM downstatesurgery.org
13 ANGIOGRAM / OPERATION #2 Extravasation of contrast from aortic arch Patient transferred to Maimonides Medical Center Underwent median sternotomy with bypass standby (right femoral cutdown) Operative findings Right innominate vein injury Laceration to proximal aortic arch Suture repair of aortic arch with pericardial flap Reimplantation of right innominate vein
14 PENETRATING NECK INJURIES
15 ANATOMY Zone I Clavicles to cricoid cartilage Zone II Cricoid cartilage to angle of mandible Zone III Angle of mandible to skull base
16 ANATOMY Anterior triangle Midline Anterior boarder SCM Mandible Posterior triangle SCM anterior Trapezius Clavicle
17 AT RISK STRUCTURES Zone I Vertebral/carotid arts. Lung/trachea Esophagus Spinal cord/cervical plexus Thoracic duct Zone III Jugulars Vertebrals/carotids Pharynx Zone II Jugulars/carotids Vertebral arts. Esophagus Larynx/trachea Spinal cord
18 INITIAL EVALUATION ATLS Airway Stridor Blood in airway Hoarseness Breathing Breath sounds Circulation IV access/vitals Disability Exposure
19 ZONE I INJURIES Hemodynamically stable CXR CTA +/- Angiogram Swallow study DL/bronchoscopy Hemodynamically unstable OR Median sternotomy +/- supraclavicular resection +/- left anteriolateral thoracotomy Proximal left subclavian art best approached by L thoracotomy
20 ZONE II INJURIES Management for hemodynamically stable patient Diagnostic imaging vs. operation vs. observation Hemodynamically unstable or obvious injury Operate
21 NECK EXPLORATION Incise along anterior boarder of sternoclidomastoid muscle (retract laterally) Encounter jugular vein Divide facial vein (giving access to cartoid artery) Proximal and distal control of vascular injuries Careful of vagus n. within carotid sheath posteriolat Examine pharynx and esophagus (better visualized in left neck) Retract carotid sheath laterally
22 ZONE III INJURIES Difficult to expose May require disarticulaton or partial resection of mandible For hemodynamically unstable Operate Standard neck incision with superior extension For hemodynamically stable Angiogram Contrast esophagram +/- FOE
23 URGENT OPERATIVE INDICATIONS Aero-digestive Airway compromise Extensive subcutaneous emphysema Mediastinal air Vascular Expanding hematoma Exsanguination/hemodynamic compromise Central neurologic deficit Soft signs of injury Dysphagia, voice changes, hemoptysis, widened mediastinum
24 MANAGEMENT/DECISION TREE
25 EXPOSURES downstatesurgery.org
26 Selective downstatesurgery.org Management of Penetrating Neck Trauma Based on Cervical Level of Injury Biffl, W et al Am J Surgery 1997; 174; year prospective study N=312 Asymptomatic and symptomatic hemodynamically stable patients (N=207) managed conservatively only 1 missed injury (esophagus) Conclusion: Selective management is safe in the asymptomatic or hemodynamically stable patient except in Zone I where liberal use of angiogram is encouraged
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