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Published on : Jan 08, 2015
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Slide 1 - Neck Trauma
Slide 2 - Penetrating trauma Blunt trauma Near - Hanging & Strangulation
Slide 3 - Penetrating Trauma Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation
Slide 4 - Pathophysiology Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous
Slide 5 - Organ System Classification Vascular ( most common ) Pharyngoesophageal Laryngotracheal Others ( cranial nerve, thoracic duct, brachial plexus, spinal cord….
Slide 6 - Vascular Three pathophysiologic mechanisms External hemorrhage Extending soft tissue hematoma, distort or obstruct the airway Disruption of cerebral perfusion ( CVA )
Slide 7 - Pharyngoesophageal Rarely causes any immediate consequence Delayed diagnosis can lead to serious soft tissue infection, mediastinitis and sepsis
Slide 8 - Laryngotracheal Small puncture wound Airflow away from respiratory tree Obstruction of airway
Slide 9 - Wound Location Classification Anterior (Sternocleidomastoid muscle ) Posterior Anterior Zone 1 ( below cricoid cartilage ) Zone 2 ( between the cricoid cartilage and mandible angle ) Zone 3 ( above mandible angle )
Slide 10 - Management of Penetrating Trauma Stabilization Critically injured patient Rapidly assessing vital functions and the area of injury Performing stabilizing interventions Initiating a diagnostic workup Definitive care No immediate life threat Violates the platysma ( explore at OR ) * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order
Slide 11 - Airway The risk of spinal cord injury is minimal Cervical cord injury in a gunshot wound victim when intubation has never been reported Preintubation radiography is significant
Slide 12 - Airway General Most difficult management dilemma: awake patient with impending airway obstruction Preoxygenation is important # Comatous patients & patients in respiratory distress require immediate intubation # It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED )
Slide 13 - Airway Method Oral & nasal intubation with or without endoscopic guidance or muscle relaxants Percutaneous transtracheal ventilation ( PTV ) Surgical airway
Slide 14 - Airway Method PVT Airway remains unprotected & uncomfortable in conscious patient Temporary intervention Complication and contraindication 1. Significant airway obstruction & penetrated airway 2. Subcutaneous emphysema, pneumothorax
Slide 15 - Airway Method Surgical Airway Last resort ( direct injury to the airway is exception ) cricothyrotomy Tracheostomy or even intubation via the wound
Slide 16 - Hemorrhage External hemorrhage Direct pressure Blindly clamping bleeding vessels is avoided Quick transfer to the operating room Inter Hemorrhage Airway compromised Zone 1 injury result in hemothorax ( thoracostomy )
Slide 17 - Definitive Management of Penetrating Trauma Unstable patient Immediate transfer to the OR Stable patient General Mandatory exploration Selective Approach
Slide 18 - Definitive Management Stable Patient General Lateral neck film CXR ( especially in zone 1 injuries ) NG tube should not be inserted Prophylactic antibiotics Mandatory exploration Selective Approach A selective method reserves operative intervention for patients with clinical signs of significant injury
Slide 19 - Clinical Findings:Require Surgical Intervention Using a Selective Approach Expanding or pulsatile hematoma Presence of a bruit Horner syndrome Subcutaneous emphysema Air bubbling through wound Hemoptysis or blood - tinged saliva Shock or active bleeding Absent peripheral pulses Respiratory distress Others are observed & undergo various diagnostic studies
Slide 20 - Other Diagnostic Studies Bronchoscopy Esophagography Esophagoscopy Angiography # Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies
Slide 21 - Disposition of Penetrating Neck Trauma No indication for surgery ==> admission for at least 24 hrs
Slide 22 - Blunt Trauma Rare, compared with penetrating trauma Motor vehicle crash or an assault Off - road vehicles
Slide 23 - Classification of injuries Larygotracheal Pharyngoesophageal Vascular : delayed dissection or thrombosis ( CVA )
Slide 24 - Four recognized mechanisms by which thrombosis can occur A direct blow to the neck A blow to the head that causes hyperextension and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels Blunt intraoral trauma Basilar skull fracture
Slide 25 - Spinal column and spinal cord injuries are more prevalent in blunt trauma
Slide 26 - Clinical Feature Physical findings may be lacking , it is important to elicit symptoms 1 .Dysphagia, odynophagia 2.Voice quality 3.Aphonia, muffled voice ( serious injury )
Slide 27 - Management of Blunt Neck Trauma Whether the patient has laryngotracheal injury?
Slide 28 - Definitive Management General C - spine X-ray CXR Additional Studies Laryngotracheal Vascular Pharyngoesophageal
Slide 29 - Additional Studies Laryngotracheal Plain radiographs CT endoscopy ( fiberoptic bronchoscopy ) ( Consult chest surgeon or ENT ? ) Vascular Angiography Color Flow Doppler ultrasound Pharyngoesophageal Threshold for performing diagnostic studies should be low Esophagram & esophagoscope ( Consult chest surgeon )
Slide 30 - Disposition of Blunt Neck Trauma Laryngeal injuries do not require immediate repair Tracheal injuries should receive prompt surgical attention
Slide 31 - Near - Hanging & Strangulation Classification of Strangulation Hanging ( most common ) Ligature strangulation Manual strangulation Postural strangulation
Slide 32 - Clinical Features Superficial & Deep Neck Respiratory (delayed mortality) Bronchopneumonia Aspiration pneumonitis Delayed airway obstruction ARDS Neuro psychiatric
Slide 33 - Management Spinal cord injury is very rare Phenytoin: useful in preventing ischemic cerebral damage Naloxone Ca2+ channel blocker
Slide 34 - Summary Structured approach to these patients, regardless of mechanism is essential to optimize outcome & avoid catastrophe