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Slide 1 - Penetrating and Blunt Neck Trauma Tintinalli Chapter 258
Slide 2 - Anatomy Complex network of neurovasuclar & muscular structures supported by various fascial planes Two methods used to describe the neck: Zones & Triangles Anterior Triangle: anteriorly by the midline; posteriorly by the SCM; superiorly by the mandible Posterior Triangle: anteriorly by the SCM; inferiorly by the clavicle; posteriorly by the anterior border of the trapezius muscle
Slide 3 - Anatomy Anterior Triangle Structures: carotid artery, internal jugular vein, vagus nerve, thyroid gland, larynx, trachea, and esophagus Posterior Triangle Structures: few vital structures, except at its base, where the subclavian artery and brachial plexus are located
Slide 4 - Anatomy Zones One: superiorly from the sternal notch & clavicles to the cricoid cartilage (injury affects both neck & mediastinal structures) Two: cricoid cartilage to the angle of the mandible Three: angle of the mandible to the base of the skull
Slide 5 - Anatomy Zone I: includes the vertebral and proximal carotid arteries, major thoracic vessels, superior mediastinum, lungs, esophagus, trachea, thoracic duct, and spinal cord Zone II: involve the carotid and vertebral arteries, jugular veins, esophagus, trachea, larynx, and spinal cord Zone III: includes the distal carotid and vertebral arteries, pharynx, and spinal cord
Slide 6 - Anatomy Fascial Planes Platysma: thin muscle covers the entire anterior triangle and the anteroinferior aspect of the posterior triangle; serves as an important planar landmark when evaluating penetrating neck injuries Deep Cervical Fascia: invest deep structures; important due to the pretracheal deep fascia’s communication to the anterior mediastinum (neck trauma can lead to mediastinitis)
Slide 7 - Initial Management ABC’s Always be ready for a cricothyroidotomy Maintain C Spine alignment until cleared via Nexus (if you believe in it) or imaging or BOTH Direct pressure for bleeding Disability: try to assess quickly if intubation
Slide 8 - Signs and Symptoms Hard (trauma more likely) Hypotension in the ED Active Arterial Bleeding Diminished Carotid Pulse Expanding Hematoma Bruit Lateralizing Signs Hemothroax > 1000 mL Air Bubbling Wound Hemoptysis Hematemesis Soft Hypotension in the field HX of Arterial bleeding Tracheal deviation Large hematoma Stridor Hoarseness Vocal cord paralysis Sub Q Air 7th cranial nerve injury Unexplained bradycardia
Slide 9 - Diagnostic Strategies Prospective study of 393 patients with penetrating neck injuries found 30% of patients with no physical findings had positive findings on surgical exploration. Another study of 223 patients found physical examination was reliable to determine which patients needed vascular or esophageal studies. However, if hard signs present, then evaluation should continue
Slide 10 - Mechanism of Injury Penetrating Injuries Blunt Injuries Strangulation
Slide 11 - Penetrating Injury Is the platysma penetrated? Stable vs. Unstable Stable Zone I injures should undergo angiography and esophagram and/or esophagoscopy Zone III injures should undergo angiography and thoracic consultation Zone II – undergo mandatory exploration or be evaluated with angiography and esophagram and/or esophagoscopy Patients with laryngotracheal symptoms require laryngoscopy & bronchoscopy Helical CT Angiogram is an option for stable patients, but sensitivity not as good for zone I & III injury patterns
Slide 12 - Evaluation Plan
Slide 13 - Blunt Injury Much more rare Symptoms may be minimal or delayed Classic symptoms include dysphonia, hoarseness, dysphagia, odynophagia, dyspnea, pain, hemoptysis, and stridor Laryngoscopy and bronchoscopy - vocal cord function, luminal integrity, and level of injury Esophagram & esophagoscopy if significant injury found to other structures or high clinical suspicion Causes 3-10% of all cervical vascular injury: Two patterns - pseudo-aneurysm or dissection can occur (new bruit or neurologic symptoms)
Slide 14 - Strangulation Severe Hoarseness & stridor are suggestive of impending airway obstruction Death from three Mechanisms Injury to the spinal cord or brain stem Mechanical constriction of the neck structures Cardiac Arrest
Slide 15 - Strangulation Treatment C spine injury is rare unless significant drop during strangulation Neurogenic pulmonary edema best prevented with PEEP Cardiac monitoring essential to follow possible dysrhythmias Watch for increased ICP (Cushings)
Slide 16 - Pearls Exsanguination is the leading cause of immediate death Esophageal injury is the leading cause of delayed death Neck wounds should never be probed & can lead to massive hemorrhage or air embolus Cervical Collars can obscure significant injury Vascular injury from blunt trauma is difficult to identify Transcervical gunshot wounds have a high incidence of visceral-vascular injury All near-hanging or strangulation patients who are comatose or AMS may have elevated ICP
Slide 17 - Reference Tintinalli Chapter 258 Rosen’s Chapter 41