Penetrating Neck Trauma - University of Tennessee … Neck Trauma Presley Regional Trauma Center...
Transcript of Penetrating Neck Trauma - University of Tennessee … Neck Trauma Presley Regional Trauma Center...
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Penetrating Neck Trauma
Presley Regional Trauma Center
Department of Surgery
University of Tennessee Health Science Center
Memphis, Tennessee
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Introduction
• Management of penetrating cervical injury
has undergone major change during the
last decade
• At the end of WWII, surgeons extrapolated
routine exploration of penetrating neck
injuries into the care of civilian injuries
• Subsequent studies documented non-
therapeutic rates ranging from 40-70 %
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Introduction
• The advent of arteriography in the early
1970s helped to better define the site and
extent of penetrating neck injury
• Mortality rates for civilian neck injuries now
range between 0-11%
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Initial Management
• Management depends on hemodynamic
stability and the zone injured
• Patients with penetrating injury and
hemodynamic instability require emergent
operative exploration
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Initial Management
• Some are comfortable observing patients
with a normal exam
• Vascular studies are reserved for those
who have hard/soft signs of injury and
hemodynamic stability
• In contrast to extremities, missed injuries
in the neck have more serious sequelae
– justifying liberal use of Angio
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• Early control of airway
• No NGT
• Angio for hemodynamically stable patients
with zone I and III injuries
• Hard signs and/or unstable = explore
• Selective management vs mandatory neck
exploration
- with zone II – no difference in outcome
Management Principles
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• The main factors are:
- Stability
- Presence of hard signs
- Location of injury
Operative vs Non-operative
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Hard Signs
• Ongoing hemorrhage
• Large or expanding hematoma
• Bruit
• Massive blood loss at scene
• Hemiparesis or hemiplegia
• Extensive subcutaneous emphysema
• Stridor
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• I – sternal notch to cricoid
- trachea, great vessels, esophagus,
thoracic duct, upper mediastinum and lung
apices
• II – cricoid to angle of mandible
- carotid and vertebral arteries, jugular veins,
esophagus, pharynx, trachea and larynx
• III – angle of mandible to base of skull
- distal extracranial carotid arteries, vertebral
arteries and jugular veins
Injury Location
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Non-operative Evaluation
• Reserved for patients with zone I or III
injuries or zone II without hard signs
– Arteriography, pharyngoesophagoscopy,
tracheobronchoscopy
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Arteriography
• Invaluable in excluding injury or planning
the operative approach for zone I or III
injuries
• Should visualize the innominate, carotid,
subclavian and vertebrals for zone I -
carotid and vertebral arteries for zones II
and III
• 4 vessel essential to exclude injury in zone
II with signs such as proximity, stable
hematoma or h/o significant hemorrhage
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Endoscopy and Esophagoscopy
• Alone, either modality has a sensitivity of
60%
• Combined - 90%
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Specific Injuries
• Vascular
– Carotid
– Vertebral
– Subclavian
• Tracheal
• Esophageal
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• Neck trauma damages cervical vessels in
25% of cases
• Penetrating trauma predominates
• 30% have associated injuries in the neck
and thorax
Cervical Vascular Injuries
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• Blunt trauma accounts for <10% of injuries
• Mortality rate - 10 - 30%
• Permanent neurologic deficit – 40%
• Evolution of approach - ligation to
revascularization
Cervical Vascular Injuries
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General Operative Approach
• Active bleeding should be controlled with
digital pressure until direct vascular control
is achieved
• Wounds should not be probed, cannulated
or locally explored
– These can dislodge clot and lead to
uncontrolled hemorrhage or embolism
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• Zone I - SCM incision +/- sternotomy
• Zone II - SCM incision
• Zone III - postauricular extension with SCM,
mandibular subluxation
Operative Approach
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• Occlusions of the ICA in patients who are
neuro intact are anticoagulated
• ICA occlusion + neuro defect = repair
• ICA non-occlusive injury +/- deficit = repair
• Improvement in neuro status with
revascularization possible even with
profound deficits
• Arteriorrhaphy, patch, IC-EC transposition
Carotid Trauma - Management
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• No specific injury is pathognomonic
• Direct compression between the angle of
the mandible and the upper cervical
vertebrae
• Adbuction, extension and rotation of the
neck causes stretch-traction injury
• Initial injury is non-occlusive and serves as
the focus for local thrombus formation and
subsequent cerebral embolization
Carotid Trauma
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• Lucid interval
• TIA, lateralizing sign
• Cervical bruit
• Neck contusion – 15%
• Horner’s and/or anisocoria – 6%
Carotid Injury - Presentation
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• Patients who are initially intact may develop
deficit – delay may be hours to months
• Stroke + blunt carotid injury = 30% mortality
• IV heparin lessens the deficit and improves
survival
• Up to 60% with dissection can demonstrate
healing with anticoagulation
Carotid Trauma
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• Incidence = 1-7%(pene), <1%(blunt)
• Mortality = 5%
• Massive hemorrhage up to 15%
• Neuro signs rarely found
• Suspect with wounds posterior to SCM
• Suspect with facet joint dislocation of
fracture through transverse foramen
Vertebral Artery Injury
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• V1 - subclavian origin to C6 TP foramen
• V2 - interosseous portion C6 – 2
• V3 - C2 to foramen magnum
• V4 - foramen magnum to basilar artery
Vertebral Artery Anatomy
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• Attempt angiographic diagnosis and therapy
• Operate if hemodynamically unstable or for
IR failure
• Operative exposure is DIFFICULT
Vertebral Artery Injury
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• Penetrating neck and chest trauma – 3%
• 20% both artery and vein damaged
• 33-40% brachial plexus injury
• 25% intrathoracic injury
• Injury from blunt trauma rare – 0.4-10%
- 1st rib = prox SC; clavicle = dist SC
Epidemiology of SCA Injuries
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• Overall MR patients reaching hospital = 34-
60%
• MR of those reaching OR = 15%
• MR for isolated arterial injuries = 60%
• MR for isolated venous injuries = 82%
Epidemiology of SCA Injuries
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• Hard signs – severe bleeding, unexplained
shock, expanding hematoma, pulse deficit,
bruit
• Soft signs – stable hematoma, mild
hypotension, proximity
• r/o associated aerodigestive tract injuries –
subq empysema, hemoptysis, hematemesis,
odynophagia
Presentation of SCA Injuries
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• Divided into 3 portions
• 1st - Aorta/innominate to medial border of
anterior scalene, under SCM; branches =
vertebral, IMA, thyrocervical trunk
• 2nd - under anterior scalene, related to
middle and upper trunks of brachial plexus;
branches = costocervical artery
• 3rd - lateral to anterior scalene to middle of
clavicle; no constant branches
Anatomic Exposures - SCA
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Surgical Approaches to the SCA
SCA exposed Incision
Proximal R SCA Median sternotomy/cervical extension
+/- clavicular resection
2nd R or L SCA Supra + infraclavicular incision
+/- clavicular resection
3rd R or L SCA Same as above
Proximal L SCA L lateral thoracotomy + supraclavicular
extension
L anterolateral thoracotomy +
sternotomy + supraclavicular extension
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• Because of collaterals – ligation tolerated
• Re-establish arterial inflow
• If critical – temporary shunting with delayed
repair
Surgical Management of SCA
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Tracheal Injury
• Simple lacerations can be repaired in a
single layer
• Complex injuries can require tracheostomy
• Extensive injuries can require delayed
reconstruction
– Cartilage graft, fascial flaps
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Tracheal Injury
• Mathison and Grillo
– Avoid searching for recurrent laryngeal nerves
– Separate tracheal and esophageal suture
lines
– Avoid tracheostomy through the repair
– Flex the neck to avoid tension on the repair
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Esophageal Injuries
• Meticulous operative dissection must be employed to avoid missed injuries
• Injuries should be debrided and repaired in two layers
• Rotation of a muscle flap over the repair will decrease the incidence of fistula formation
• Extensive injury may require cervical esophagostomy
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Management
Penetrating Neck Wound
airway control
Unstable or Zone II injury
with hard signs
Immediate Exploration
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Management
Penetrating Neck Wound
airway control
Stable
Zone I
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Zone I
Angiography
Esophagoscopy +/-
Barium Swallow
Tracheobronchoscopy
Any Positive
Appropriate Exploration
All Negative
Observation
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Management
Penetrating Neck Wound
airway control
Stable
Zone II
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Zone II
Selective Management -
Angiography
Pharyngoesophagoscopy
vs Barium Swallow
Tracheobronchoscopy
Any Positive
Neck Exploration
All Negative
Observation
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Management
Penetrating Neck Wound
airway control
Stable
Zone III
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Zone III
Angiography
Pharyngoesophagoscopy
Tracheobronchoscopy
Any Positive
Appropriate Exploration
All Negative
Observation
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Summary
• Patients with obvious major penetrating
cervical injuries need early control of the
airway
• Presence of hard signs, radiologic or
endoscopic diagnosis and zone of injury
dictate operative management
• Appropriate choice of exposure in zone I
injuries is essential
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Summary
• Significant injuries to the larynx, trachea,
carotid or esophagus are not common
• Associated with relatively high morbidity
and mortality