Penetrating Neck Trauma. Herve J. LeBoeuf, MD Francis B. Quinn, MD

Similar documents
Tips & Techniques in Operative Surgery II: Neck Exploration

Evaluation & Management of Penetrating Wounds to the NECK

McHenry Western Lake County EMS System Paramedic, EMT-B and PHRN Optional Continuing Education 2019 #3 Penetrating Neck Trauma

Penetrating Neck Injuries. Jason Levine MD Lutheran Medical Center July 22, 2010

Trauma. Neck trauma zones. Neck Injuries 1/3/2018. Basic principles A ; Airway B ; Breathing C ; Circulation D ; Disability E ; Exposure

Tony Capizzani, MD, FACS

Management of Penetrating Neck Trauma

Penetrating Neck Trauma January 1999

A CASE PRESENTATION AND DISCUSSION ON HEAD AND NECK TRAUMA

DR. SAAD AL-MUHAYAWI, M.D., FRCSC. ORL Head & Neck Surgery

Neck-2. Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology

The Neck the lower margin of the mandible above the suprasternal notch and the upper border of the clavicle

International Journal of Scientific & Engineering Research, Volume 5, Issue 9, September ISSN

The Neck. BY: Lina Abdullah & Rahaf Jreisat

Penetrating Trauma in Pediatric Patients. Heidi P. Cordi, MD, MPH, MS, EMTP, FACEP, FAADM EMS WEEK 2017

Esophageal Perforation

vel 2 Level 2 3,034 c-spine evaluations with CSR Level 3 detected injury only 53% of the time. Level 3 False (-) rate 47%

OBJECTIVE: To obtain a fundamental knowledge of the root of the neck with respect to structure and function

TRACHEOSTOMY. Tracheostomy means creation an artificial opening in the trachea with tracheostomy tube insertion

How Do I Manage Penetrating Neck Trauma?

Lecture 2: Clinical anatomy of thoracic cage and cavity II

PEMSS PROTOCOLS INVASIVE PROCEDURES

Tracheo-innominate artery fistula (TIF) is an uncommon

Case Review: Airway Trauma Case 1: Tracheal Transection Pre-hospital:

Anatomy of the Thyroid Gland

Thyroid and Parathyroid Glands

Management of Airway Trauma I:

Alexander C Vlantis. Selective Neck Dissection 33

Combat Extremity Vascular Trauma

Posterior Triangle of the Neck By Prof. Dr. Muhammad Imran Qureshi

Ballistic Trauma. L Yuko Shimotake, MD Kings County Hospital Center September 22, 2016

ISPUB.COM. Quick Review: GSW to the Chest: The Effect And Impact of High-Velocity Gun Shots. B Phillips CASE REPORT THE OPERATING ROOM

Veins of the Face and the Neck

Tracheal Trauma: Management and Treatment. Kosmas Iliadis, MD, PhD, FECTS

Diagnosis & Management of Kidney Trauma. LAU - Urology Residency Program LOP Urology Residents Meeting

Skin Anatomy and Physiology

Prevertebral Region, Pharynx and Soft Palate

Chapter 29 - Chest Injuries

Chapter 44 Neck Trauma

LIVER INJURIES PROFF. S.FLORET

Ears. Mouth. Jowls 6 Major Bones of the Face Nasal bone Two

Neck Ultrasound. Faculty Info: Amy Kule, MD

THE DESCENDING THORACIC AORTA

Anatomy: head and Neck (6 questions) 1. Prevertebral Flexor Musculature (lying in front of the vertebrae) include all, EXCEPT: Longus Colli.

THYROID & PARATHYROID. By Prof. Saeed Abuel Makarem & Dr. Sanaa Al-Sharawy

Alexander C Vlantis. Total Laryngectomy 57

In ESH we usually see blunt chest trauma but penetrating injuries also treated here (usually as single injuries, like stab wound)

9/10/2012. Chapter 49. Learning Objectives. Learning Objectives (Cont d) Thoracic Trauma

EAST MULTICENTER STUDY DATA DICTIONARY. Temporary Intravascular Shunt Study Data Dictionary

Trauma Overview. Chapter 22

For the following questions, indicate the letter that corresponds to the SINGLE MOST APPROPRIATE ANSWER

Tympanic Bulla Temporal Bone. Digastric Muscle. Masseter Muscle

Anterior triangle of neck

Face and Throat Injuries. Chapter 26

Large veins of the thorax Brachiocephalic veins

The ABC s of Chest Trauma

CHEST TRAUMA. Dr Naeem Zia FCPS,FACS,FRCS

Breast conservation surgery and sentinal node biopsy: Dr R Botha Moderator: Dr E Osman

Imaging of Thoracic Trauma: Tips and Traps. Arun C. Nachiappan, MD Associate Professor of Clinical Radiology University of Pennsylvania

11/3/16. Understanding and Addressing Strangulation. Jenifer Markowitz ND, RN, WHNP-BC, SANE-A, DF-IAFN. Copyright Notice

10/14/2018 Dr. Shatarat

Esophageal injuries. 新光急診張志華醫師 Facebook.com/jack119

The Primary Survey. C. Clay Cothren, MD FACS. Attending Surgeon, Denver Health Medical Center Assistant Professor of Surgery, University of Colorado

Esophageal injuries. Pre-test /11/10. 新光急診張志華醫師 Facebook.com/jack119. O What is the most common cause of esophageal injuries?

Proceedings of the World Small Animal Veterinary Association Mexico City, Mexico 2005

Chapter 16. Thoracic Injuries

Lesson Plans and Objectives: Review material for article Prep work for article Picture recovery Review for placement on-line.

ACDF. Anterior Cervical Discectomy and Fusion. An introduction to

Respiratory System. Clinical notes. Published on Second Faculty of Medicine, Charles University (

CHEST INJURIES. Jacek Piątkowski M.D., Ph. D.

Focused History and Physical Examination of the

Brain & Vascular Choke. Definition. The Choke Hold Don Muzzi MD & Larry Lovelace DO. Submission Breakdown UFC Events 4/27/17! 15% of Cardiac Output

Dr. Weyrich G07: Superior and Posterior Mediastina. Reading: 1. Gray s Anatomy for Students, chapter 3

Candidate s instructions Look at this cross-section taken at the level of C5. Answer the following questions.

Introduction to Emergency Medical Care 1

Injuries to the Hands and Feet

Lecture 01. The Thyroid & Parathyroid Glands. By: Dr Farooq Khan PMC Date: 12 th March. 2018

Emergency Approach to the Subclavian and Innominate Vessels

ATLS: Initial Assessment and Management. SAUSHEC Medical Student Lecture Series

Subclavian and Axillary Artery Aneurysms

PRE-HOSPITAL EMERGENCY CARE COURSE.

International Journal of Health Sciences and Research ISSN:

Mediastinum and pericardium

SCHOOL OF ANATOMICAL SCIENCES Mock Run Questions. 4 May 2012

Aortic arch pathology. Cerebral ischemia following carotid artery stenosis.

Head & Neck Contouring

Lung & Pleura. The Topics :

Anatomy notes-thorax.

ISPUB.COM. GSW To The Face: "Hunting Camp" C Perry, B Phillips CASE REPORT

Superior and Posterior Mediastinum. Assoc. Prof. Jenny Hayes

1. Thyroxine (inactive form) also called T4 (90% of the secretion). 2. Triiodothyronine (active form) also called T3 (10% of the secretion).


Surgical Anatomy of the Neck. M. J. Jurkiewicz, John Bostwick. Surgical Clinics of North America, Vol 54, No 6, December 1974.

Objectives. Thoracic Inlet. Thoracic Inlet Boundaries. Thoracic Inlet Sagittal View ANTERIOR SCALENE ANTERIOR SCALENE

Right lung. -fissures:

Chapter 29 - Chest_and_Abdominal_Trauma

Chapter 28. Objectives. Objectives 01/09/2013. Bleeding and Soft-Tissue Trauma

Children are not small adults Children are Not Small Adults Anatomic considerations Pliable bony & cartilagenous structures - Significant thoracic inj

Transcription:

Penetrating Neck Trauma Herve J. LeBoeuf, MD Francis B. Quinn, MD

Introduction 5-10% of all trauma Overall mortality rate as high as 11% Major vessel injury fatal in 65%, including prehospital deaths Attending physician must have excellent knowledge of anatomy Otolaryngologist as part of major trauma team

Historical Perspective/ pre WW I Ligation of the major vessels described as early as 1522 by Ambrose Pare Ligation was the procedure of choice for vascular injury through WW 1 Associated mortality rates up to 60% Significant neurologic impairment in 30 %

Historical / post WW II Mandatory exploration of all penetrating neck wounds, through the platysma Fogelman and Stewart reported Parkland Memorial Hospital experience of early, mandatory exploration with mortality of 65 vs.. 35% for delayed exploration 40% to 60% rate of negative explorations with mandatory exploration Present mortality for civilian wounds is 4% to 6%

Anatomy/Zone I Bound superiorly by the cricoid and inferiorly by the sternum and clavicles Contains the subclavian arteries and veins, the dome of the pleura, esophagus, great vessels of the neck, recurrent nerve, trachea Signs of significant injury may be hidden from inspection in the mediastinum or chest

Anatomy/Zone II Bound inferiorly by the cricoid and superiorly by the angle of the mandible Contains the larynx, pharynx, base of tongue, carotid artery and jugular vein, phrenic, vagus, and hypoglossal nerves Injuries here are seldom occult Common site of carotid injury

Anatomy/Zone III Lies above the angle of the mandible Contains the internal and external carotid arteries, the vertebral artery, and several cranial nerves Vascular and cranial nerve injuries common

Fascial Layers 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

Ballistics Over 95% of penetrating neck wounds are from guns and knives, remainder from motor vehicle, household, and industrial accidents The amount of energy transferred to tissue is difference between the kinetic energy of the projectile when it enters the tissue, and the kinetic energy of any exiting fragments or projectiles The velocity of the projectile is the most significant aspect of energy transfer (K.E. = 1/2 mv^2

Ballistic cont... Muzzle velocity less than 1000 ft/s is considered low velocity.22 and.38 caliber handguns have a velocity of 800 ft/sec.357 magnum and.45 as high as 1500 ft/sec High power rifles: 220-3000 ft/sec Shotguns at less than 20 feet -- 1200-1500 ft/sec

Ballistic cont. Injuries inflicted with high power rifles, shotguns at less than 20 feet, and.357 and.45 caliber handguns can cause extensive damage extending beyond the path of the projectile and should be explored Stab wounds do not have this effect Beware of the stab wound just over the clavicle -- the subclavian vein is at high risk

Stabilization/Airway Established Airway be prepared to obtain an airway emergently intubation or cricothyrotomy beware of cutting the neck in the region of the hematoma -- disruption there of may lead to massive bleeding must assume cervical spine injury until proven otherwise

Breathing Zone I injuries with concomitant thoracic injuries pneumothorax hemopneumothorax tension pneumothorax

Circulation 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 Careful of IV in arm unilateral to subclavian injury

History Obtain from EMS witnesses, patient Mechanisms of injury - stab wounds, gunshot wound, high-energy, low-energy, trajectory of stab Estimate of blood loss at scene Any associated thoracic, abdominal, extremity injuries Neurologic history

Physical Examination 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 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

Radiographs CXR - inspiratory/expiratory films to assess for phrenic nerve injury, look for pneumothorax Cervical spine film to rule out fractures Soft tissue neck films AP and Lateral Arteriograms, contrast studies as indicated

Preoperative Preparation Surgeon and staff ready for emergent/urgent tracheotomy Gentle cleansing of wound, betadine paint only Prep vein donor site, and chest for possible thoracotomy Avoid NG tube until airway secure and patient anesthetized

Penetrating neck trauma Diagnosis Vascular injury Laryngotracheal injury Pharynx/esophagus injury Signs and symptoms Shock Hematoma Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck Subcutaneous emphysema Airway obstruction Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia Subcutaneous emphysema Hematemesis Dysphagia or odynophagia

Exploration vs. Observation Many experts have adopted a policy of selective exploration Decreased number of negative explorations, increased number of positive explorations Decreased cost of medical care, maybe No increase in mortality when adjunctive diagnostic studies and serial exams performed Patients taken to OR if clinical exam changes, around 2% in most studies

Site/Zone I Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy High morbidity of exploration, thus suspicion must be great before taking the patient to OR Cardiothoracic surgery consultation a must Angiography is essential

Site/Zone II Few injuries will escape clinical examination Most carotid injuries occur here Adjunctive studies, except barium swallow and esophagoscopy where indicated, are not necessary Symptomatic zone II injuries can generally be safely managed by observation

Site/Zone III High rate of vascular injury, often multiple Often difficult to obtain proximal and distal vessel control Exploration has high rate of injury to cranial nerves Adequate exposure may require mandibular subluxation or mandibulotomy Angiography needed to delineate site of injury Embolization techniques of greatest value here

Clinical Setting Observation requires admission to an intensive care unit where serial examination can be performed by a surgeon Adjunctive studies must be available at all times and at a moments notice Absence of these dictates exploration of all patients - such as in a rural setting

Pharyngo Esophageal Gastrografin swallow followed by Barium if negative Flexible ± rigid esophagoscopy Invert the mucosal edges and close with two layers of absorable sutures JP drain and muscle flap

Airway DL where laryngeal injury is suspected Mucosal tears are closed with absorbable sutures Cover raw surfaces with nasal, buccal, or local mucosal flap A keel or soft stent is placed when denuded areas are opposed Tracheotomy one ring below injury when high tracheal injury Suprahyoid muscle release for primary closure of segmental defect

Vascular The subclavian and internal jugular veins can be ligated without adverse effect Major arteries should be repaired where possible except the vertebral which can be ligated Partial lacerations can be closed primarily -- vein patches will help prevent subsequent stenosis High velocity wounds produce a surrounding area of contusion which may be thrombogenic and which must be resected; then primary reanastamosis if possible

Vascular cont. When tension is required, vein grafts from the sphenous or internal jugular are interposed In central neurologic deficits: repair the artery when there are minimal deficits, with gross deficits restoration of flow can convert ischemic infarcts into hemorrhagic ones -- the artery should be ligated a deterioration in neurologic status dictates arteriography and reexploration EC-IC bypass when irreparable injury to ICA

Conclusions Maintain a healthy respect for apparently minor neck wounds because of potential fatal outcome for initially benign appearing injuries Do not try to infer trajectories of gunshot wounds from clinical or radiographic studies Careful history and complete physical exam with appropriate ancillary studies will avoid missed injuries Arteriography for zone I and zone III injuries Vascular injuries most immediately life-threatening, missed esophageal injury causes late mortality