penetrating neck trauma c mccrossin, r1. objectives anatomy clinical features diagnosis management...
TRANSCRIPT
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Penetrating Neck Trauma
C McCrossin, R1
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Objectives• Anatomy
• Clinical Features
• Diagnosis
• Management
• Disposition
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Not Covered:• C-Spine injuries
• Blunt neck trauma
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Definition• Penetrating neck trauma is any injury
that penetrates through the platysma
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Zones of the Neck
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Neck Zones-The Basics• Zone II is the most exposed and accessible to
direct surgical visualization and easier vascular control
• Zones I and III have structures that lie deeper making diagnosis and management of vascular injury more difficult.
• Important to note which zone contains the injury and if the platysma is penetrated (without deep probing)
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Neck Zone I• Proximal carotid artery• Vertebral artery• Subclavian artery• Major vessels of the upper mediastinum• Apices of the lungs• Esophagus• Trachea• Thyroid• Thoracic duct• Spinal cord
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Neck Zone II• Carotid artery
• Vertebral artery
• Larynx
• Trachea
• Jugular vein
• Recurrent laryngeal nerve
• Spinal cord
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Neck Zone III• Distal carotid artery
• Vertebral artery
• Distal jugular vein
• Salivary and parotid glands
• Cranial nerves IX-XII
• Spinal cord
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Pretracheal layer of the deep cervical fascia inserts on the anterior pericardium putting patients with penetrating aerodigestive injuries at risk for mediastinitis
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Diagnosis
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Clinical Features• Rarely do you have an isolated injury to
the neck (polytrauma more common)
• Anatomical injuries to look for:– Vascular– Laryngotracheal– Esophageal– Neurological
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“Soft” Signs• Hemoptysis/hematemesis• Oropharyngeal blood• Dyspea• Dysphonia/dysphagia• Subcutaneous air• Chest tube air leak• Non-expanding hematoma• Focal neurologic deficits
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Vascular Injuries (Common Exam Question)
• “Hard” Signs of Vascular injury:– Shock– Airway obstruction– Inspection
• Pulsatile bleeding• Expanding hematoma
– Palpation• Thrill• Absent radial pulse
– Auscultation• Bruit
– Ischemia• Cerebral (stroke symptoms) • Upper limb (pulse deficit)
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Vascular Injuries• Morbidity and Mortality:
– Exsanguination– Hematoma and airway compromise– Direct vascular injury and subsequent occlusion– Bullet embolization– Air embolism
• Late complications:– Traumatic aneurysm– AV fistula formation (may present a few weeks
after trauma)
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Laryngotracheal injuries• Signs of Tracheal Injury
– Subcutaneous emphysema (most common)
– Respiratory distress– Hemoptysis– Hoarseness– Air bubbling from wound
(hard sign)– Deformities of landmarks– Deformity of neck
landmarks– Mediastinal air– Stridor
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Esophageal Injuries• Clinical Features
– Dysphagia– Oral bleeding/blood in NG– Subcutaneous emphysema– Resistance to ROM of neck
• May be asymptomatic
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Esophageal Injuries• Least common injury to occur
• Most common injury to miss
• Mortality secondary to mediastinitis
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Neurological Injuries• Spinal cord• Cranial Nerve• Peripheral Nerve• CNS• Be wary of associated arterial injuries with
neurological deficits because most nerves are located close to large arteries
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Cranial Nerves
1.Glossopharyngeal
2.Hypoglossal
3.Vagus
4.Sympathetic Trunk
5.Phrenic Nerve
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Diagnosis• Physical Exam
• Vitals• Evaluate patients for “hard” and “soft” signs of injury
• Radiology• Mandatory CXR and Neck views• CT Angio• Angio• U/S• Esophagography
• Scopes• Esophagoscopy (rigid/flexible)• Laryngoscopy• Bronchoscopy
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Physical Exam• Will miss 1/4 vascular injuries with
physical exam alone (all neck zones)
• Better at ruling out airway injuries
• Most commonly miss esophageal injuries
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X-Ray• CXR to rule out pneumothorax,
chylothorax, hemothorax
• Lateral neck films• Can demonstrate retropharyngeal air, tracheal
deviation• Cervical spinal injuries
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Angiography• Gold standard for evaluating possible
vascular injuries
• Invasive
• Potentially therapeutic
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MR-Angiography• Used for assessment of vascular
injuries
• Not good for bony structures
• Limited use in trauma patient b/c of need for proper monitoring and MR-incompatible equipment
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Helical CT Angiography• Highly sensitive and specific for vascular
injuries (NPV 98%, PPV 100%)» Trauma Reports Nov/Dec 2006
• Cannot treat the vascular injury and patients may still require angiography
• Difficult to assess the subclavians
• Widely used in neck trauma
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Helical CT• CT alone is a highly sensitive diagnostic
tool
• Negative CT does not rule out aerodigestive injuries
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Helical CT• Inaba et al 2006 evaluated the use of CT in
penetrating neck trauma in all zones• 91 patients (34 GSW, 57 Stab)• Compared CT against a gold standard of
surgery/followup/all other imaging• CT was 100% sensitive, 94% specific• No injuries were missed with 85% follow-up
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Endoscopy• Flexible endoscopy is primary means to
investigate laryngotracheal trauma (average FN rate of 20%)
• More difficult to evaluate esophagus and pharynx than the laryngotracheal system
• May require contrast swallow imaging to detect esophageal injuries in the cervical region (sensitivity reportedly as low as 60%)
• Rigid endoscopy is more sensitive but technically more difficult and not always available
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Color Flow Doppler• Non invasive• Highly operator dependent• May not be available at night or on
weekend• Lots of artifacts (ie Bone)• Difficult to examine smaller vessels• Only real use is as an alternative in
stable patients with zone II injuries
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Summary Of InvestigationsDIGESTIVE VASCULAR LARYNGOTRACHEAL
Physical Exam Physical Exam
Angio (gold standard)
Physical Exam
Lateral neck xray/CXR
Lateral Neck xray CT Angio sensitive and specific
Endoscopy
CT cannot rule out
Esophagoscopy
CXR, Lateral Neck
Color Flow US
Laryngoscopy
Bronchoscopy
Contrast Swallow
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Management: The Debate• Long historical debate over mandatory exploration
and selective management• Prior to WWII expectantly watching stable patients
resulted in a mortality rate of up to 35%• Mandatory exploration reduced mortality rates to 6%• Mandatory exploration results in a 50-60% negative
exploration rate• However there is little morbidity or mortality with a
negative surgical neck exploration• Need to strike a balance that minimizes both mortality
rates and the rate of negative surgical explorations
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Management• Airway
– RSI is considered safe
• Breathing– Beware of pneumo– Hemothorax/
chylothorax also possible
• Circulation– Don’t clamp– Direct pressure to control
bleeding
• Exposure– Look for other injuries– Do not probe neck injury
• Disability– C-spine precautions if
indicated
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Quick word on airway• RSI is safe• Neck is a tight
compartmentalized space which may appear ok externally but significant airway compromise can be secondary to edema or hematoma
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Management Approach (Common Exam Question)
No further work-up
Platysma Not PenetratedStable
Immediate OR
Platysma Penetrated-Unstable
-Expanding hematoma-Severe active/pulsatile bleeding
Zone I or IIITriple Scope + CT Angio
or OR exploration
Zone IIIf no physical findings -> No Tests
If any soft findings then triple scope plus CT Angioor Exploration in OR
Selective Management-based on zone
-hard and soft signs
Platysma PenetratedStable
Neck Trauma
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Zone I• Managed selectively because of difficulty
obtaining intra-operative exposure• Investigations
– Arteriogram to exclude great vessel injury– Bronchoscopy to identify laryngotracheal injuries– Combination of esophagography and
esophagoscopy to evaluate for potential esophageal injuries
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Zone I (cont.)• Is routine arteriography mandatory for
penetrating injuries of zone 1?– 138 pts, 10 year retrospective study– Results demonstrated CXR and PE have a
NPP of 100% at ruling out arterial injury– Conclude that routine arteriography may
not be necessary » Eddy et al 2000
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Zone II• Controversial Region in stable patients
• Trend is towards selective management vs mandatory surgery
• Easiest zone to both diagnose injury and best for gaining adequate intraoperative exposure
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How Good is P/E at Detecting Zone II Vascular Injury?
• Prospective use of physical exam (P/E) in 145 patients with zone II injuries
• F/U included repeated P/E over 23 hours plus 2 week post injury F/U
• Use of “hard signs” to decide on surgery:
» Active bleeding, expanding hematoma, thrill over the wound, pulse deficit, central neuro deficit
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Role of Physical Exam alone in Zone II Vascular Injuries
Use of Physical Exam in Penetrating Zone II Injuries
Immediate OR3 False Positives/
2 of 3 had non vascinj requiring repair
28 (90%)Major Arterial
or venous injuryrequiring repair
31 (21%) Hard Signs
3 Showed arterialabnormalities
2 abn were benign1 small lac in carotid identified
23 underwent angio5 b/c of prox to vert art
18 b/c injury in other zone
91 observedwith no consequence
114 (79%)No Hard Signs
145 PatientsType Title Here
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Zone II Vascular Injuries (cont.)
• Authors concluded that physical exam alone can be used to exclude significant vascular injuries in zone II with a FN rate comparable to angiography.
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Role of CT in Zone II Injuries• Prospective; 42 patients with Zone II injuries• All pts had CT, esophagography, then OR• 2 esophageal injuries (out of 4) missed by
P/E, CT and esophagography• All patients with tracheal and carotid injuries
were identified by CT alone• Conclusions: CT has little impact on
diagnosis and management » Gonzalez et al 2003
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Zone II (cont.)• The debate over mandatory OR vs selective
management of zone II injuries is ongoing however most centers have adopted a selective approach
• Physical exam alone may be sufficient to exclude significant vascular injury
• CT may be beneficial at identifying bullet trajectory
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Zone III Vascular Injuries• Require studies of the cerebral
circulation, upper airway, and esophagus
• All symptomatic patients with zone III injuries require diagnostic evaluation of both esophagus and arteries
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Zone III• Absence of hard signs reliably excludes
surgically significant vascular injuries in zone III suggesting angiography is not necessary
• Hard signs in a stable patient should mandate angiography because these vascular injuries may be amenable to endovascular therapy
» Ferguson et al 2005
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Laryngotracheal Injuries• 10% of penetrating neck injuries include
a laryngotracheal injury
• Rarely are these injuries occult
• Mandatory laryngoscopy with any of the previous mentioned signs
• Bronchoscopy for symptomatic injuries in zones II and III
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Esophageal Injury• Found in ~ 7% of penetrating neck trauma• Combination of physical exam, endoscopy,
and esophagography can reliably diagnose all significant injuries
» Demetriades et al 2001
• Most of these injuries require EARLY operation to decrease morbidity and mortality secondary to mediastinitis
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Neurological Injuries• 10% of asymptomatic patients with gunshot
wounds to the trunk had associated spinal injury
• Actual prevalence of spinal cord and neurological injury is controversial but bad outcome if overlooked
• Approach varies depending on signs/symptoms and mechanism of injury
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Does Mech of Injury matter?
Harry Whittington
Why is his pic in my presentation?
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Shot in the neck by this evil man:
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Great example of penetrating neck trauma reaching all three anatomical
zones!
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Ballistics• Tissue penetration and trajectory dependent
upon many different factors (muzzle velocity, bullet design, etc) therefore difficult to predict internal injury and imaging warranted (angio, CT angio)
• Gun-shot wounds to the neck are not absolute indications for exploration
» Demetriades et al 1996
• CT is very useful at tracking path of bullet
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What should we be doing in Calgary?
• Zone I & III injuries: If stable and regardless if symptomatic or asymptomatic then triple scope (esophagoscopy/laryngoscopy/bronchoscopy + CT angio)
• Zone II injuries: If stable and asymptomatic then observe for 24 hours (no investigations), if any soft signs then triple scope plus CT angio or OR
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Practical Tips• CXR to r/o Pneumo• IV’s and Central lines
on opposite side of injury
• Trendelenberg to decrease air embolism
• Ancef to decrease risk of infection (esp mediastinitis)
• Consult early
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The “Do Nots”• Never clamp vessels (direct pressure)
• Don’t poke/probe (may release hematoma)
• Don’t remove impaled objects
• Don’t place an NG
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SUMMARY• Does the injury penetrate the platysma?• Management based on stable/unstable,
zones, and presence of “hard” and “soft” signs
• RSI is considered safe• Evidence suggests that physical exam is a
powerful tool which can rule in and rule out significant vascular injury
• Imaging required in high velocity penetrating trauma
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Summary (Cont.)• Angio is gold standard for vascular
injuries, CT angio also highly sens/spec
• Esophageal injuries most commonly missed =>risk of mediastinitis (deep fascia anatomy)
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The End