Neck

trauma

Done by:
Dr. MUNAWARUZZAMAN BIN ABDUL MANAN
PAKAR PERUBATAN KECEMASAN
JABATAN KECEMASAN
HOSP QUEEN ERLIZABETH
KOTA KINABALU
SABAH

Type of neck injury

- Penetrating
Gunshot wound
Stab wound
- Blunt
MVA
Sport injury
Strangulation
Blows
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 Zone III

Zone II
Zone I
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 Zone I
Bound superiorly by the cricoid and
inferiorly by the sternum and clavicles
- The great vessels (subclavian vessels,
brachiocephalic veins, common carotid
arteries, and jugular veins),
- Aortic arch
- Trachea
- Esophagus
- Lung apices
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ZONE II
Bound inferiorly by the cricoid and
superiorly by the angle of the mandible
- Carotid and vertebral arteries
- Jugular veins
- Pharynx, Larynx, Trachea
- Esophagus, base of the tunge
- Phrenic , vagus , and hypoglossal nerves
Injuries here are seldom occult
Common site of carotid injury
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ZONE III
Lies above the angle of the mandible
- Carotid arteries
- Jugular veins
- The salivary and parotid glands
- Esophagus, pharynx
- Major cranial nerves
Vascular and cranial nerve injuries
common
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morbidity and mortality

Zone I injuries are associated with the highest
morbidity and mortality rates.
more common among males than females.
Most are adolescents and young adults

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 Neck trauma accounts for 5-10% of

all serious traumatic injuries
missed cervical injuries secondary to
neck trauma result in a mortality rate
of greater than 15%.
10% of neck wounds lead to
respiratory compromise. Loss of the
airway patency may occur
precipitously, resulting in mortality
rates as high as 33%.
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Frequancy
Thrombosis is the most common complication
of vessel injury, occurring in 25-40%
the most common sites of vascular injuries
internal jugular vein (9%) and carotid artery
(7%).
Injury to the pharynx or the esophagus occurs
in 5-15% of cases.
The larynx or the trachea is injured in 4-12%
of cases.
Major nerve injury occurs in 3-8% of patients
sustaining penetrating neck trauma.
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Vascular injury
Hard evidence:
severe active hemorrhage, shock
unresponsive to volume expansion,
absent ipsilateral upper extremity,
neurologic deficit
Soft evidence:
bruit, widened mediastinum ,
hematoma
Decreased upper extremity pulse,
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shock response to volume expansion

Laryngotracheal injury
Subcutaneous emphysema
Airway obstruction
Sucking wound
Stridor
Dyspnea
Hemoptysis
Hoarseness
Dysphonia
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Pharynx/esophagus injury
Subcutaneous emphysema,
Hematemesis
Dysphagia
Odynophagia

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Approach
&
Management
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Primary survey
Airway
Breathing

Intubation vs. Surgical Air

Circulation

IV access, Immediate Explor

disability
exposure
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Airway
Established Airway
be prepared to obtain an airway
emergently
intubation or cricothyrotomy
Be aware of cutting the neck in the
region of the hematoma -- disruption
there may lead to massive bleeding
must assume cervical spine injury until
proven otherwise
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Breathing
Zone I injuries with concomitant
thoracic injuries
pneumothorax
hemopneumothorax
tension pneumothorax

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Circulation
Bleeding should be controlled by pressure
Do not clamp blindly or probe the wound
depths
The absence of visible hemorrhage does
not rule out
Two large bore IVs
Careful of IV in arm unilateral to
subclavian injury
Do not remove objects protruding from the
neck in the ER
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 Cross-match, hematologic analysis,

chemistries, urinalysis, coagulation profile,
blood gas, toxicologic analysis
B-hCG for female
Urine cath.
CXR inspiratory /expiratory films to assess
the lung, mediastinum and any phrenic nerve
injury
Cervical spine film to rule out fractures
Soft tissue neck films AP and Lateral
Arteriograms, contrast studies as indicated
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Secondary survey
history
Obtain from any witnesses or patient
Mechanisms of injury - stab wounds, gunshot
wound, high-energy, low-energy, trajectory of
stab
Estimate of blood loss at scene
Any associated thoracic, abdominal,
extremity injuries
Neurologic history
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examination
Thorough head and neck exam using
palpation and stethoscope to search for thrills
and bruits
Neuro exam: mental status, cranial nerves,
and spinal column
Examine the chest, abdomen, and extremities
Be sure to examine the back of the patient as
unsuspected stab or gunshot wounds have
been missed here
Dont blindly explore wound or clamp vessel
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Zone I
Adequate exposure for exploration and repair
may require sternotomy, clavicle resection, or
thoracotomy
suspicion must be great before taking the
patient to OR because high mortality rate.
Cardiothoracic surgery consultation a must
4 vessel Angiography is advocated by surgeon
because difficulty of identify injury
intraoperative
2 prospective study show only 5% of zone I
injury need operation
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Zone II
Few injuries will escape clinical examination
Most carotid injuries occur here
algoriyhm
*Several study have suggest of contrast enhance CT to
demonstrate the injury and aid for further invasive
investigation or exploration
*Furthermore studies shown CT angio. More to be
useful and comparable to conventional angiography in
evaluation vascular inj.
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 *Finally some expert recommend

ipsilateral exploration despite
increase incidence of negative
exploration and increase hospital cost
None of these algorithm for
management of penetrating zone II
had shown superiority over the
others*
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Zone III
Upper neck injury with evidence of vascular
injury required prompt CT angiography
Embolotherapy can be used for temporary
or definitive management except for ICA
Direct pharyngoscopy suffice to exclude
aerodigestive trauma
Endovascular stenting or embolization
especially in zone I & III should be
considered
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Exploration vs. Observation

Many experts have adopted a policy of
selective exploration
Decreased number of negative explorations,
increased number of positive explorations
Decreased cost of medical care, maybe
No increase in mortality when adjunctive
diagnostic studies and serial exams
performed
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*Exploration
Most common approach in anterior of
SCM
Collar incision is reversed for isolated
aerodigestive inj. Or for bilateral
exploration
Major arteries should be repaired where
possible except the vertebral which can be
ligated
Veins can be ligated EXCEPT bilateral IJV
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 Partial lacerations can be closed primarily

-- vein patches will help prevent
subsequent stenosis
High velocity wounds produce a
surrounding area of contusion which may
be thrombogenic and which must be
resected; then primary reanastamosis if
possible
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Aerodigestive injury in EXPLORATION

DL where laryngeal injury is suspected
Aerodigestive should repaired primary by
synthetic absorbable suture
IF tandem injury occur a well vascularized
flap should be interpose between the repairs
to prevent aerodigestive fistula

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 Drain-if suspect aerodigestive injury

To Prevent lethal mediastinitis
and In combined aerodigestive and vascular
injuries the aerodigestive repair should be drained
to the contralateral neck to prevent break down of
the vascular repair from gastrointestinal secretion
raw surfaces Cover with nasal, buccal, or local
mucosal flap
A keel or soft stent is placed when loss areas are
opposed
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In central neurologic deficits:

repair the artery when there are minimal
deficits, with gross deficits restoration of
flow can convert ischemic infarcts into
hemorrhagic ones -- the artery should
be ligated
a deterioration in neurologic status
dictates arteriography and reexploration
EC-IC bypass when irreparable injury to
ICA
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Blunt neck trauma

Severe Blunt neck trauma can result
in significant laryngeal and vascular
injury
Best modality in stable pt contrast
enhance CT to demonstrate the
injury and aid for further invasive
investigation or exploration
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laryngeal injury
If suspect of minor laryngeal injury
can treated with airway protection,
head of bed elevation and possibly
antibiotics
Major laryngeal injury required
operative exploration and repaired

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Blunt vascular injury

Usually involves the internal and common
carotid artery
there may also be injury to the vertebral
vessels without symptomatology & come later
with neurological deficit
Four vessels angiography and CT angiography
are preferred diagnostic modalities
Severity of the deficits and time of diagnosis
are strongly associated with outcome
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 The current recommendation is for

operative repair for surgically
accessible lesions.
Systemic Anticoagulant with heparin
appears to improve neurologic
outcome and is therefore
recommended for surgically
inaccessible lesions
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 If suspect esophagial injury

ESOPHAGOSCOPY /ESOPHAGOGRAM

If +ve operation exploration ll next step

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Conclusions:
Maintain a healthy respect for apparently minor
neck wounds because of potential fatal outcome
for initially benign appearing injuries
Do not try to infer trajectories of gunshot wounds
from clinical or radiographic studies
Careful history and complete physical exam with
appropriate studies will avoid missed injuries
Arteriography for zone I and zone III injuries
Vascular injuries most immediately life-threatening
& missed esophageal injury causes late mortality
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THANK YOU

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