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Slide 2 - Neck Trauma 5-6% as isolated injury Fatality rates: stab wounds 1-2% gunshot wounds 5-12% rifle/shotgun 50% preventable deaths 50%
Slide 3 - Causes of Neck Trauma Blunt Trauma Diving injuries Assault Vehicular crashing into windshield /steering wheel seat belt whiplash “clothesline” Penetrating Assault stab wounds gunshot wounds Vehicular broken glass
Slide 4 - Triangles of the Neck
Slide 5 - Anatomy of the Neck
Slide 7 - Zones of the Neck
Slide 8 - Zones of the Neck Zone I highest mortality Zone II most frequent site of injury lower mortality Zone III neurological distal carotids pharyngeal injuries
Slide 9 - Blunt Neck Trauma Frequently involves C5-C6 Rescue/ transport neck immobilization avoid intubation in symptomatic/ high risk Neurologic injury
Slide 10 - Penetrating Neck Trauma 70 - 80% of injuries vascular/aerodigestive tract injury Hemorrhage 20-30% Mortality 5-6 %
Slide 11 - Signs of Significant Injury in Penetrating Neck Trauma VASCULAR INJURY Shock Active bleeding Large/expanding hematoma Pulse deficit
Slide 12 - AIRWAY INJURY Dyspnea Stridor Hoarseness Dysphonia or voice change Subcutaneous emphysema
Slide 13 - DIGESTIVE TRACT INJURY Hemoptysis Dysphagia/odynophagia Hematemesis Subcutaneous emphysema
Slide 14 - Injured Structures from Penetrating Neck Wounds SYSTEM INJURED PATIENTS(%) Arterial 516 (12.3) Venous 769 (18.3) Digestive 354 ( 8.4) Respiratory 331 ( 7.8) Source: Adapted from JA Asensio, et al. Management of Penetrating Neck Injuries: The Controversy Surrounding Zone II Injuries In JA Asensio and JA Weigelt (eds.), The Surgical Clinics of North America Contemporary Problems in Trauma Surgery. 71:2, 1991;
Slide 15 - Initial Care ABCs of Trauma Resuscitation ventilation treatment of shock baseline neurologic exam
Slide 16 - Airway Assessment Spontaneous respiration conscious stridor tachypnea dyspnea frothing No respiration intubate airway obstruction shock
Slide 17 - Hemorrhage/ Shock Control bleeding direct digital pressure occult bleeding hemothorax - CTT Venous access fluid replacement/ blood central line
Slide 18 - History/ Physical Exam Time factor Manner of injury Pre-existing disease Vital signs location/ extent of injury neurologic deficit ? probing
Slide 19 - Penetrating Neck Trauma Algorithm
Slide 20 - Presentation - GSW, POE: L supraclavicular, No POX, Hemorrhagic shock - hacking wound to the neck with external bleeding; shock - punctured wound to the neck, stable vital signs - punctured wound to the neck. stable VS, suddenly develops dyspnea
Slide 21 - Presentation - 1.5 cm stab wound zone II, stable vital signs with subcutaneous emphysema - punctured wound,nape, in hypovolemic shock, unable to move or feel LLE
Slide 22 - Mandatory Exploration negligible m/m for (-) exploration comparative cost of work-up 17-25% (+) exploration in asymptomatic patients 83% significant injury in transcervical gunshot wounds high mortality for delayed operations: 67% for vascular injury 44% for esophageal injury
Slide 23 - Selective Exploration 40-60% incidence of negative exploration medical cost of unnecessary surgery availability of accurate, non-invasive diagnostic facilities mandatory exploration based on high velocity military injuries
Slide 24 - Rules on Exploration All symptomatic patients are explored Work-up is irrelevant in the presence of clinical signs of injury Zone I injuries liberally explored difficult vascular control disastrous consequences with delay
Slide 25 - Diagnostic work-up Angiography gold standard for vascular injury more in Zones I and III Esophagography water soluble/ barium contrast 50-90% sensitivity Esophagoscopy 50-90% sensitivity rigid / flexible
Slide 26 - Surgical Management Vascular injuries Carotid Artery blunt injury - 20-40% mortality permanent neurologic impairment in 40-60% repair or ligation of penetrating lacerations comatose patients acute stroke after revascularization
Slide 27 - Vascular injuries Vertebral artery hyperextension/rotation chiropractic manipulation soccer/volleyball injury heavy metal rock music Usually diagnosed angiographically thrombosis/hemorrhage
Slide 28 - Esophagus Difficult diagnosis clinically evident in 20-30% exponential increase in MR with late diagnosis, 100% if undiagnosed Primary repair when feasible cutaneous pharyngostomy/ esophagostomy
Slide 29 - Larynx and Trachea Subcutaneous emphysema, hoarseness,respiratory distress debridement reduction of fractures coverage of exposed cartilage closure of tracheal defects tracheostomy