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Management of Penetrating Neck Trauma

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Slide 1 - Management of Penetrating Neck Trauma Shashidhar S. Reddy, MD, MPH Shawn D. Newlands, MD, PhD
Slide 2 - Types of Weapons Low velocity – knives, ice picks, glass High velocity – handguns, shotguns, shrapnel K=1/2mv^2
Slide 3 - Guns <
Slide 4 - Ballistics
Slide 5 - Ballistics
Slide 6 - Ballistics
Slide 7 - Anatomy
Slide 8 - Anatomy Zone III Zone II Zone I
Slide 9 - Incision for Neck Exploration:
Slide 10 - Incisions for Neck Exploration:
Slide 11 - Incidence and Mortality
Slide 12 - Initial Management Airway Intubation vs. Surgical Airway Breathing Circulation IV access, Immediate Exploration Examination Determine weapon trajectory
Slide 13 - Signs of Injury: Vascular Shock, Profuse bleeding, Evolving stroke, Expanding hematoma, hemoptysis, hematemesis, unequal pulses, bruits or thrills
Slide 14 - Signs of Injury: Larynx/Trachea Subcutaneous emphysema, Hoarseness, Respiratory distress, Stridor Esophagus Neck pain, Blood in saliva, Fever, Odynophagia
Slide 15 - Management of the Stable Patient: Wound Penetrates Platysma? The Old Standard: Yes No Immediate Neck Exploration Observation/Discharge Laryngoscopy Esophagoscopy
Slide 16 - The Old Standard: Based on wartime experiences Fogelman et al (1956) showed that immediate neck exploration led to better outcomes in study group for vascular injuries. Led to rate of negative neck explorations in > 50% Arteriogram slowly began to gain acceptance as screening tool before exploration, especially for zone 1 and 3 injuries (hard to detect on physical).
Slide 17 - Arteriogram Zone 1 and Zone 3 vascular injuries are difficult to visualize by physical exam, making arteriogram useful in these patients. Flint et al (1973) reported absence of P.E. findings in 32% of pts. with major zone 1 vascular injury. Arteriogram can be accompanied by embolization.
Slide 18 - A Newer Algorithm Mansour et al 1991 retrospective study
Slide 19 - Newer Algorithm (Mansour) 63% of the study population was in the observation group. Entire study population had a mortality of 1.5%, similar to those in more rigorous treatment protocols. Similar results obtained in other large studies with similar protocols (e.g. Biffi et al 1997). Still uses the Arteriogram in asymptomatic patients with zone 1 injury.
Slide 20 - Points of Controversy: Most trauma surgeons accept observation of select patients similar to the Mansour algorithm. Study by Eddy et al questions the necessity for arteriogram / esophagoscopy in asymptomatic zone 1 injury (use of P.E. and CXR resulted in no false negatives). Other noninvasive modalities than arteriogram exist for screening patients for vascular injury.
Slide 21 - CT scan Can aid in identifying weapon trajectory and structures at risk. Should only be used in stable patients. Gracias et al (2001) found that use of CT scan in stable patients was able to save patients from arteriogram indicated by other protocols 50% of the time and avoid esophagoscopy in 90% of tested patients who might otherwise have undergone it.
Slide 22 - Duplex Ultrasonography Requires the presence of reliable technician and radiologist. A double blinded study by Ginsburg et al (1996) showed 100% true negative, 100% sensitivity in detecting arterial injury, using arteriography as the gold standard.
Slide 23 - Management of Vascular Injuries: Common carotid: repair preferred over ligation in almost all cases. Saphenous vein graft may be used. Shunting is rarely necessary. Thrombectomy may be necessary. Internal carotid: Shunting is usually necessary Vertebral: Angiographic embolization or proximal ligation can be used if the contralateral vertebral artery is intact. Internal Jugular: Repair vs. ligation.
Slide 24 - Esophageal Injury: Best detected by combination of esophagoscopy and esophagram in symptomatic patients. Injection of air or methylene blue in the mouth may aid in localizing injuries. Close wounds in watertight 2 layer fashion. Controlled fistula with T-tube or exteriorization of low non-repairable wounds Small pharyngeal lesions above arytenoids can be treated with NPO and observation 5-7 days All patients should be NPO for 5-7 days.
Slide 25 - Laryngeal/Tracheal Injury Thorough Direct Laryngoscopy for suspicious wounds Tracheotomy for suspected laryngeal injury
Slide 26 - Conclusions Mandatory neck exploration is no longer considered acceptable ABC’s Physical Exam is probably the most useful diagnostic tool. Intervention should be directed to sites of possible injury Non-invasive diagnostic modalities should be considered.