· defines as violation of platysma muscle.
If a penetrating neck wound does not violate platysma then the patient can be discharged from ED.
· transcervical gunshot is associated with a high rate of vital organ damage (70%) - only 20% need a therapeutic operation however
· other penetrating trauma carries a 10-15% risk of needing a therapeutic operation
· Airway control maintaining cervical immobilization.
· Early intubation without use of muscle relaxant
· Fibreoptic intubation using LA
· Cricothyroidotomy if intubation is not possible
· Haemorrahge control with digital pressure or foley catheter through wound
What are the important symptoms in neck trauma
· Airway and breathing compromise –
only 1/3 patients with emphysema have injury to larynx, pharynx or esophagus
· Expanding haematoma, pulsitile neck mass
· Dysphagia or haematemesis
· Neurological deficit: Horner’s syndrome
· Laryngeal trauma due to direct injury. Symptoms include:
— Soft voice
· oesophageal trauma associated with damage to other organs
— gt vessels
— Cx spine
· Can also cause rupture of thoracic oesophagus or OGJ
Penetrating injury more common on left as most assailants are right-handed
Zones, stability and symptoms
When assessing the patient the management algorithm depends on whether they are unstable (hypotensive with haemorrhage)
symptomatic (as defined above) but stable
zone of injury
· Zone 1 sternum notch ® cricoid
· Zone 2 Cricoid ® angle of mandible
· Zone 3 Superior to angle of mandible
· For the haemodynamically unstable patient with uncontrolled haemorrhgae: operative exploration irrespective of zone of injury.
· Zones 1 injuries
— if stable whether symptomatic or not assess with CT neck (with arterial phase contrast – CTA) and chest and endoscopy (esophagoscopy, bronchoscopy and laryngoscopy) and esophagography using water soluble contrast. When used alone esophagoscopy or esophagography will detect 60% of injuries whilst used together they will detect 90%. These studies are used to find occult esophageal injuries and guide operative approach (thoracotomy may be required).
— Unstable: Explore. For right side a median sternotomy is often required. For left sided injuries a left antero-lateral thoracotomy.
· Zone 2 injuries
— Symptomatic: Operative exploration.
— Asymptomatic: Universal mandatory exploration of asymptomatic patients produces a high number of negative explorations. These patients may be safely observed as inpatients for 12-24 hours. Transcervical GSW requires CT examination even if asymptomatic.
· »20% of penetrating neck trauma will show vascular injury on angiography
· »10% will have vascular injury requiring repair
· physical examination picks up virtually all of the injuries requiring intervention
· routine studies pick up more injuries but not more that require intervention
· Zone 3 injuries
— Asymptomatic: observation as inpatient
— Symptomatic: Angiogram showing both internal and external carotid arteries on both sides. This allows for angio-embolization or stenting of any injuries which are difficult to expose surgically in this zone.
· 10% of penetrating neck trauma is associated with airway compromise
· 1 attempt at intubation
— without muscle relaxant
— fibre optic if available
— cricothyroidotomy if unsuccessful
· control external bleeding with pressure
· consider foley catheter tamponade if simple pressure is unsuccessful (can put one through the wound into the chest and pull back to compress bleeding subclavian vessels)
· cardiac arrrest with penetrating trauma mandates emergency room thoracotomy
— control bleeding
— x-clamp the aorta
— aspirate r atrium for air
GA. Supine. Arms tucked. Towel between shoulders. Head ring. Head turned to opposite side if C-spine cleared. Prep chest and neck.
—Trail of safety
· Neck incision along border SCM: curve incision posteriorly 3cm below the angle of mandible to avoid mandibular and cervical branch of facial nerves. Skin. Platsyma. Expose anterior border of SCM.
— Insert self-retaining retractor.
— SCM retracted laterally
— Omohyoid retracted / divided
· Ligate the common facial veins of the IJ
· The common facial vein is marker for carotid bifurcation
· Mobilisation of carotid sheath
— Ansa cervicalis can be sacrificed
Seek and protect (9,10,11,12 cranial nerves)
spinal accessory nerves
— Gain proximal then distal control of carotid in virgin territory before entering a haematoma:
— Proximal: isolate the CCA using a vascular sling
— Distal: Haematoma may extend to angle of jaw. Can enter haematoma and insert a Fogarty into the vessels (ICA and ECA) for control.
· Venous injury initially controlled with compression above & below
· Oesophagus – insert a large bore NG or boogee.
— Approach the esophagus by retracting the carotid sheath laterally and enter the plane between it and trachea. Middle thyroid veins and Inferior thyroid artery will be encountered. The RLN may be difficult to identify.
— Esophagus can also be approached by passing lateral to carotid sheath, retracting the sheath medially and entering the plane between it and the spine. The exposure is limited but the scope for injury of RLN is less.
— Fill the field with water and ask for air to be blown into NG tube to see bubbles.
— Mobilised from trachea
— Dissect directly on oesophagus to preserve RLN’s
· If vascular & oesophageal / tracheal injury
— Repair vascular
— Repair oesophagus / trachea
— Interpose strap muscle between to ¯ chance of oesophagovascular fistula
· 20% of vascular injuries in penetrating neck trauma
· 6% of penetrating neck injuries
· expose with standard SCM incision
· consider diarticulation of the jaw +/- vertical osteotomy for base of skull lesions – these are difficult and a strong retractor under the jaw and divide the posterior belly digastric
· direct repair – a clean injury (stab) may be amenable to direct suture or repair with interposition graft (synthetic or vein) or patch.
—Give heparin 5000U if feasible
—Open the artery remove thrombus with fogarty
Ligation can be used:
o Ligating the common carotid is less likely to lead to stroke as back bleeding via ICA
o Some surgeons ligate the ICA only if the patient already has a profound neurological deficit >4 hours.
o If there is no backflow of the distal ICA
· interposition saphenous vein graft
· transposition for IC injuries (onto External carotid stump)
· if no neurological deficit and the injury is very high then ligation may need to be done; otherwise repair
· in the absence of neurological deficit repair should be undertaken if at all possible
· use a shunt while undertaking repair for all but the most minor injuries
· repair of ‘minor’ injuries is controversial
— intramural bleeding and obstructing intimal defects probably do need repair
· asymptomatic traumatic occlusion may result in late complications
— high occlusion may be more risky to repair than to leave
If there is uncontrollable back-bleeding from an inaccessible ICA stump then insert a fogarty, put two clips and cut it for damage control.
· 4% of penetrating neck trauma
· 15% MR in hospital
· MR from venous injury much higher than from arterial injury
· Folley balloon tamponade technique
· varying surgical approaches
— supraclavicular curving incision over clavicle, then downward over deltopectoral groove, subperiosteal excision of medial clavicle
— median sternotomy for proximal injury
— L Anterolateral thoracotomy for injury on the L
· repair arteries with end to end anastamosis; may require an interposition graft (ususally synthetic)
· ligate only in the critical situation
· rarely any neurological problem
· angiography and embolisation
· for severe bleeding complex approach medial to carotid sheath; sweeping longus coli off the bone; opening the vertebral foramen and ligating the vessel
· Arrest intra-operative bleeding with bone wax and try angio/embolization later
· injuries to the parenchyma can be repaired with an absorbable suture
· sialoceles or fistulas usually respond to aspiration and compression
· persistant fistulas are an internal fistula can be formed over a no 6 feeding tube through the mucosa of the mouth and secured with suture. Saliva usually stops draining after 7 days and the tube can be removed 3 days later
· 85% confined to the neck
· laryngoscopy, bronchoscopy and oesophagoscopy are mandatory for the stable patient with a suspected injury
— air bubbling through the wound
— subcutaneous emphysema
· surgical approach is through a longitudinal or transverse neck incision. Thoracotomy is very seldom required
· small tracheal wounds with good apposition of edges can be observed – advance the ET tube cuff beyond the injury to eliminate the air leak
Can insert a tracheostomy tube through hole as a damage control measure.
· simple repair is all that is required in most cases (absorbable suture)
· tracheostomy is only indicated for extensive injuries - delayed reconstruction may be required in the unstable patient - usually defects of 3cm can be primarily closed
· undisplaced fractures of the larynx can be managed non-operatively
· most of the rest can be repaired primarily
· often missed
· pain on swallowing, haematemesis and subcutaneous emphysem are predictive of this injury
· contrast swallow and endoscopy for diagnosis
· if diagnosed early primary repair in one or two layers is indicated
· Damage control option is to put a closed suction drain adjacent to the wound, and close esophagus with a purse string around injury to produce a controlled esophageal fistula
· delayed injuries may not be possible to close primarily
— closure over a T-tube (24 Fr)
— exclusion procedures
· fistula though a wound with high fat content
· conservative treatment with TPN or low fat diet usually heals it
· open ligation of the duct and other fancy manoeuvers can be done if it persists for >2 weeks