VASCULAR NECK TRAUMA

Case 1

Presentation to Lithgow 19M, riding motorcycle in the bush- helmet, no

leathers Felt sudden sharp severe pain in R anterolateral

neck Brought by friends to Lithgow Hospital Entry wound over anterolateral R SCM near angle of

mandible, neck swelling

CT neck Lightgow - metallic FB 9mm R neck, parapharyngeal haematoma with tracheal deviation

Therefore arranged for urgent transfer to Trauma Centre- Westmead Hospital

Westmead Hospital- Primary Survey

Airway: Speaking in sentences, hoarse voice. No

stridor/resp distress. Trachea and uvula deviated to left. No subcut emphysema or crepitus No drooling/odynophagia/dysphagia Zone 3 R sided puncture wound over SCM

B: SaO2 100% RA, equal air entry, normal RR, no respiratory distress

Primary Survey (cont.)

C: HR 97, BP 180/70; non-expanding non-pulsatile R neck swelling in SCM, no bruit heard

D: GCS 15/15, vocal hoarseness and deviated uvula, moving all limbs spontaneously, no focal neurological deficits, no other cranial nerve abnormalities

Secondary Survey

Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness

Chest: No chest tenderness, equal AE, vesicular breath sounds

Abdomen: soft, non-tender Pelvis: stable and non-tender Upper & lower limbs: NAD

Evaluation

Zone 3 penetrating neck trauma (above angle of mandible)

Potential airway compromise due to extrinsic haematoma

Moderate-high risk for vascular neck injury due to location of entry wound and haematoma

No sign of acute life threatening vascular compromise (exsanguination/haemorrhage/stroke)

Management

Urgent assessment of airway No stridor or respiratory distress Nasendoscopy performed by ENT:

Oropharyngeal haematoma with mild swelling Normal vocal cords & movement Normal cranial nerves

No need for immediate intubation, if any deterioration for anaesthetic r/v and gaseous intubation

Deemed stable for transfer to CT angiography with medical escort

Management (cont)

IV dexamethasone to minimise airway oedema

O2 therapy via Hudson mask 2x large bore cannulae; 1L of

Hartmann’s administered intravenously; analgesia

ADT and cephazolin administered

Imaging

Imaging report

2x metallic foreign bodies- one at level of C2, one embedded in SCM

6mm ECA pseudoaneurysm 2.5cm above angle of mandible

Further management

Admission to ICU for airway, circulatory and neuro observations

Vascular consultation Aspirin Semi-electively 3-4 days post injury R

Cerebral & carotid angiogram for management of pseudoaneurysm with coiling performed.

No immediate complications; d/c home on oral antibiotics

Case 2

Presentation to WMH- Major Trauma Call

58M awoken by partner stabbing his R neck with kitchen knife

Walk in to ED Major trauma call on arrival

Primary Survey

Airway: Speaking in sentences No stridor; no tracheal deviation 2cm laceration upper zone 2 over R SCM with

small non-pulsatile non-expanding haematoma No active bleeding No crepitation/emphysema No dysphagia/odynophagia/drooling

Breathing: SaO2 95%, equal air entry, vesicular breath

sounds, no respiratory distress

Primary Survey (cont)

C: HR 80, BP 140/85, small haematoma at area of stab wound

D: GCS 15/15, moving all limbs spontaneously, no focal neurological deficits, no cranial nerve abnormalities

Secondary Survey

Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness

Chest: No chest tenderness, equal AE, vesicular breath sounds

Abdomen: soft, non-tender Pelvis: stable and non-tender Upper & lower limbs: NAD

Evaluation

Zone 2 penetrating neck trauma (between cricoid cartilage and angle of mandible)

Stable from airway/breathing/circulatory perspective

Potential injury to anterior neck vasculature

Deemed safe for transfer for CT angiogram of head and neck

Management

6L O2 via Hudson Mask 2x large bore cannulae, IV Hartmann’s

solution IV cephazolin, ADT NBM CT angiogram of head & neck performed

Imaging

Imaging report

26mm x 20mm x 15mm subcutaneous haematoma anterolateral to R SCM superficial to inferior aspect of parotid gland

Small locule of gas in R SCM Vessels intact

Further Management

HDU admission for airway, circulation observations

For exploration of neck wound with ASU and vascular team early the next day

Operative Findings

Expanding R anterior neck haematoma- evacuated

Stab wound tract explored- penetration through platysma to lacerated sternocleidomastoid belly

Dissection to R IJV- intact R ICA, vagus nerve, identified- intact

Further Progress

Returned to HDU postoperatively for airway & circulatory monitoring

No immediate postoperative complications

Discharged the next day on oral antibiotics

25% of head/neck trauma5-10% all arterial injuryCarotid injury- 10-30% mortality; 15-60% permanent neurologic deficit

Vascular Neck Injuries

Relevant Anatomy

Subcl aa & vvJugular vvCCATracheaOesophagus, thyroid

CCAICA, ECAJugular vvLarynxHypopharynxCr X, XI, XII

ICA, ECAJugular vvLat pharynxCr VII, IX, X, XI, XII

Relevant Anatomy (cont.)

Relevant Anatomy (cont.)

Vascular traumatic injuries

Complete or partial transection Intimal flap/dissection Aneurysm Pseudoaneurysm Fistula Extrinsic compression Thromboembolism as a result of intimal

injury

Sequelae

Haemorrhage Airway compression, exsanguination,

concealed haematoma Distal ischaemia

Either due to vessel injury or thromboembolism

Strokes- ACA/MCA (carotid injury), PCA/posterior (vertebral injury)

Damage to nearby structures

Penetrating neck injury (>90%) Injuries through platysma indicate

propensity for injury to deep structures Gunshot wounds and projectiles

Low velocity- unpredictable trajectory High velocity Cavitation and blunt type injury from

concussive forces Stab/knife

Straight and more obvious path Less tissue damage

Blunt Neck Trauma (<10%)

Seatbelt injury Hanging/ligature/strangulation Punching/kicking Hyperextension/hyperrotation/contusion

Mechanism is translocational & shear forces

Spectrum from intimal injury (more common) to transection (less common)

Associated with dislocation/fracture

Mandibular, temporal bone fractures can be a/w carotid/jugular injury

Vertebral aa injury in general rare- usually a/w C-spine pathology #C-spine (inc Lateral mass #) Ligamentous injury Rotation/hyperextension Near-hanging Extreme chiropractic manoevres

Iatrogenic injury

CVC insertion Cerebral Angiography C-spine surgery, transsphenoidal, skull

base surgery Radiotherapy (stenosis) Nerve blocks (vertebral aa injury)

Comorbid injuries

Airway – pharynx, larynx, trachea Pneumothorax, haemothorax (Zone 1) Nerve injuries

Cranial VII, IX, X, XI, XII Brachial plexus Cervical sympathetic chain (Horner’s)

C-spine, mandibular, temporal fractures Oesophagus Parotid, salivary glands, lymph nodes Thyroid (Zone 1)

Emergent Resuscitation

Airway

High comorbidity with airway injury & compromise

Assess for: Airway patency- stridor, resp distress, hoarseness Expanding haematoma Emphysema/crepitus/drooling/dysphagia

ENT r/v if possible (+/- nasendoscopy) May require

trache(/cricothyroidotomy/intubation), exploration or stenting

If unstable will require emergent OT +/- trache

Breathing

General principles apply Give Supplemental O2

Optimise tissue O2 delivery Assess chest expansion & for subcut

emphysema Need CXR

May have comorbid chest injury in high risk mech (eg MVA)

Zone 1- risk of assoc haemo/pneumothorax Index of suspicion for aspiration

Circulation

General principles of resuscitation apply Large bore IV access Fluid resuscitation, Xmatch, possible

transfusion Direct compression of severe external

bleeding- finger/foley catheter in wound If unstable – immediate OT

Circulation (cont)

Assess for “Hard” signs of vascular injury Pulsatile bleeding or haematoma Expanding haematoma Shock + ongoing bleeding Absent pulses Neurovascular symptoms- stroke/TIA

symptoms Thrills, bruits

Circulation (cont)

“Soft” signs – warrant further investigation Severe bleeding from neck/pharynx Diminished pulses- superficial temp artery Small haematoma Fractures of skull base, temporal bone,

fracture d/location C-spine Injury in anatomical area Ipsilateral Horner’s Cranial IX-XII dysfunction Widened mediastinum

Disability

If suspicion of C-spine injury- hard collar Focal neurology in stroke territory

should alert to possible vasc injury Cranial nerve VII --> XII (except VIII) Horner’s syndrome (compression of cervical

chain) Brachial plexus injury

Other Injuries on Secondary Survey Aerodigestive – oesophagus & pharynx

Drooling Odynophagia, dysphagia

Summary

Airway injury/compromise common and may r/q emergent management

If unstable from airway/circulatory point of view needs immediate operative management including exploration

Expanding haematoma may cause airway compromise

Stroke symptoms, bruits, thrills are a hard sign of vascular injury

If stable can go on to have further imaging

Investigation

Bloods

Hb, haematocrit (blood gas or formal) BSL- must optimise O2 & glucose

delivery ABG in airway/breathing compromise

Plain radiography

CXR & neck XR Foreign bodies Injury to lung apices- haemo/pneumothorax Mediastinal widening Surgical emphysema, aerodigestive injuries (C-spine fractures)

Scanning

Duplex USS useful for Zone 2 injuries- unhelpful for Z1 or 3

CT brain & CTA neck CT angiogram may show aneurysm,

dissection, fistulae etc (esp with blunt trauma) or occult injury

Localisation of FB CT brain valuable predictor of outome-

infarct on CTB has high mortality, poor neurologic prognosis

Endovascular, operative, supportive

Management

Supportive/preop care

Nurse in HDU environment Supplemental O2 Fluid resuscitation Correct hypoglycaemia

Anticoagulation for intimal injuries- high risk of thromboembolism; IV heparin followed by 3/12 warfarin

Operative management

Mandatory exploration of penetrating neck wounds beyond platysma used to be gold standard- 1800’s till 1980’s

Fogelman & Stewart (1956)- 6% mortality with mandatory exploration, 35% without

In 1980’s- increasing operations with negative findings

More selective approach adopted now

Indications for urgent surgery Airway compromise Haemodynamic instability Active pulsatile haemorrhage Expanding haematoma

Indications for surgery (other) Arterial injury requiring primary repair High index of suspicion of injury Gunshot wounds, penetration through

midline Ongoing bleeding Need for exploration of other structures

Indications for angiography +/- endovascular intervention

Assessment of zone 1 & zone 3 injuries unable to be visualised otherwise

Embolisation of persistent ECA bleeding Embolisation of osseus verterbal canal

vert aa injury Covered stentgrafts- penetrating

wounds/AVF’s/pseudoaneuryms in surgically inaccessible areas, patients who are unfit for surgery, injury to brachiocephalic trunk, proximal CCA/SCA

Procedure

Supine position, bolster between scapulae, neck extended, head rotated; access from base of skull to xiphisternum

Zone 1- oblique supraclavicular incision; may require median sternotomy; thoracic surgical referral

Zone 2- standard carotid incision- anterior border of SCM Zone 3- similar to Z2 but may r/q mandibulotomy or

subluxation; 2cm below mid mandible, 1cm facial notch (avoid marginal br facial nn)

Arteries should be repaired (primarily if possible; bypass if simple repair not possible)

ECA may be ligated if necessary (if ICA ok) Venous injuries (inc IJ) may be ligated. Complex venous

repair not recommended If trachea/oesophagus injured, repair should be protected

by SCM