Management of Penetrating Neck Trauma
Ottawa Civic
MVA, aphasia, R hemiplegia
Types of Weapons


Low velocity – knives, ice picks, glass
High velocity – handguns, shotguns, shrapnel
Guns
Ballistics
Anatomy
Anatomy
Incidence and Mortality
Signs of Injury:
Signs of Injury:
Initial Management
Management of the Stable Patient:
The Standard:
The Standard:


Based on wartime experiences
Fogelman et al (1956) :



immediate neck exploration-> better outcomes in vascular
injuries.
negative neck explorations in > 50%
Arteriogram?


screening tool before exploration
zone 1 and 3 injuries


hard to detect on physical
Safe answer on board exam…
Arteriogram

Flint et al (1973):


negative P.E. in 32% of pts. with major zone 1 vascular injury.
Arteriogram can be accompanied by treatment (e.g.
embolization).
A Newer Algorithm
Mansour et al 1991 retrospective study
Newer Algorithm (Mansour)


63% of the study population was in the observation
group.
Overall mortality 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).

NOTE: Arteriogram in asymptomatic patients with zone 1
injury.
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.
CT scan



Can id weapon trajectory and structures
only in stable patients.
Gracias et al (2001)

CT scan in stable patients:


able to save patients from arteriogram indicated by other protocols 50% of
the time
avoid esophagoscopy in 90% of tested patients who might otherwise have
undergone it.
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.
Is this really wise??
Incision for Neck Exploration:
Incisions for Neck Exploration:
Management of Vascular Injuries:

Common carotid:





Internal carotid:


Shunting is usually necessary
Vertebral:



repair preferred over ligation in almost all cases.
Saphenous vein graft may be used.
Shunting is rarely necessary.
Thrombectomy may be necessary.
Angiographic embolization
proximal ligation can be used if the contralateral vertebral artery is intact.
Internal Jugular: Repair vs. ligation.
Esophageal Injury:

Diagnosis:



Controlled fistula with T-tube



esophagoscopy and esophagram in symptomatic patients.
Injection of air or methylene blue in the mouth may aid in
localizing injuries.
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.
Laryngeal/Tracheal Injury


Thorough Direct Laryngoscopy for suspicious wounds
Tracheotomy for suspected laryngeal injury
Thoracic Trauma
Thoracic Trauma

2nd leading cause of trauma deaths



after head injury
10-20% of all trauma deaths
Many deaths are preventable
Thoracic Trauma

Mechanisms of Injury

Blunt Injury




Deceleration
Compression
Penetrating Injury
Combination
Thoracic Trauma

Anatomical Injuries







Thoracic Cage (Skeletal)
Cardiovascular
Pleural and Pulmonary
Mediastinal
Diaphragmatic
Esophageal
Penetrating Cardiac
Thoracic Trauma

Hypoxia




Hypercarbia



 in intrathoracic pressure relationships
 level of consciousness
Impairments to cardiac output





hypovolemia
pulmonary V/P mismatch
 in intrathoracic pressure relationships
blood loss
increased intrapleural pressures
blood in pericardial sac
myocardial valve damage
Acidosis – final result

hypoperfusion of tissues
Thoracic Trauma

Initial exam directed toward life
threatening:

Injuries





Open pneumothorax
Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade
Thoracic Trauma

Assessment Findings

Mental Status


Pulse


narrow PP, hyper- or hypotension, pulsus paradoxus
Ventilatory rate & effort


absent, tachy or brady
BP


decreased
tachy- or bradypnea, labored, retractions
Skin

diaphoresis, pallor, cyanosis, open injury, ecchymosis
Thoracic Trauma

Assessment Findings

Neck


Chest


contusions, tenderness, asymmetry, abN a/e, bowel
sounds, abnormal percussion, open injury, impaled
object, crepitus, hemoptysis
Heart Sounds


tracheal position, SQ emph, JVD, open injury
muffled, distant, regurgitant murmur
Upper abdomen

contusion, open injury
Thoracic Trauma

Assessment Findings


ECG (ST segment abnormalities, dysrhythmias)
History





Dyspnea
Pain
Past hx of cardiorespiratory disease
Restraint devices used
Item/Weapon involved in injury
Thoracic Trauma
Specific Injuries
Rib Fracture

MC chest wall injury from direct trauma



More common in adults than children
Especially common in elderly
Most commonly 5th - 9th ribs

Poor protection
Rib Fracture

Fractures of 1st and 2nd second require
high force




Frequently have injury to aorta or bronchi
Occur in 90% of patients with tracheo-bronchial
rupture
May injure subclavian artery/vein
30% will die
Rib Fracture

Fractures of 10 to 12th ribs can cause damage
to underlying abdominal solid organs:



Liver
Spleen
Kidneys
Rib Fracture
 Management




PPV
Analgesics for isolated trauma
Non-circumferential splinting
Monitor elderly and COPD patients closely


Broken ribs can cause decompensation
Patients will fail to breathe deeply and cough, resulting in poor
clearance of secretions
Sternal Fracture
Uncommon, 5-8% in blunt chest trauma
 Large traumatic force
 Direct blow to front of chest by


Deceleration



steering wheel
dashboard
Other object
Sternal Fracture

25 - 45% mortality due to associated trauma:






Disruption of thoracic aorta
Tracheal or bronchial tear
Diaphragm rupture
Flail chest
Myocardial trauma
High incidence of

myocardial contusion, cardiac tamponade or
pulmonary contusion
Sternal Fracture
 Management




Establish airway
High concentration oxygen
Assist ventilations as needed
IV NS/LR


Restrict fluids
Rule out associated injuries
Flail Chest

Usually secondary to blunt trauma


Most commonly in MVA
Also results from





falls from heights
industrial accidents
assault
birth trauma
More common in older patients
Flail Chest
Mortality rates 20-40% due to associated
injuries
 Mortality increased with






advanced age
seven or more rib fractures
three or more associated injuries
shock
head injuries
Flail Chest

Consequences of flail chest

Respiratory failure due to

pulmonary contusion
inadequate diaphragm movement

Paradoxical movement of the chest




must be large to compromise ventilation
Increased work of breathing
decreased chest expansion
 pain
Flail Chest



Suspect spinal injuries
Establish airway
Assist ventilation




Treat hypoxia from underlying contusion
Promote full lung expansion
Consider need for intubation and PEEP
Mechanically stabilize chest wall

questionable value
Flail Chest

Management

IV of LR/NS



Avoid rapid replacement in hemodynamically stable patient
Contused lung cannot handle fluid load
Monitor EKG

Chest trauma can cause dysrhythmias
Simple Pneumothorax

Incidence



10-30% in blunt chest trauma
almost 100% with penetrating chest trauma
Morbidity & Mortality dependent on


extent of atelectasis
associated injuries
Simple Pneumothorax



a # rib lacerates lung
Usually well-tolerated in the young & healthy
Severe compromise can occur in the elderly or
patients with pulmonary disease

Degree of distress depends on amount and speed of
collapse
Simple Pneumothorax



HDI and respiratory distress
High index of suspicion
Chest tube when in doubt before CXR
Open Pneumothorax

If the trauma patient does not ventilate well with an
open airway, look for a hole






May be subtle
Abrasion with deep punctures
Opening in the chest wall
Sucking sound on inhalation
HDI/resp distress
SQ Emphysema
Open Pneumothorax


Profound hypoventilation may occur
communication between pleural space and
atmosphere


Prevents development of negative intrapleural
pressure
Results in ipsilateral lung collapse

inability to ventilate affected lung
Open Pneumothorax

V/Q Mismatch






shunting
hypoventilation
hypoxia
large functional dead space
Pressure may build within pleural space
Return from Vena cava may be impaired
Open Pneumothorax



Cover chest opening with occlusive dressing
Assist with positive pressure ventilations prn
Monitor for progression to tension
pneumothorax
Tension Pneumothorax

Incidence



Penetrating Trauma
Blunt Trauma
Morbidity/Mortality


Severe hypoventilation
Immediate life-threat if not managed early
Tension Pneumothorax

Pathophysiology

One-way valve forms in lung or chest wall



Air enters pleural space, but cannot leave
Pressure collapses lung on affected side
Mediastinal shift to contralateral side

Reduction in cardiac output
 Increased
intrathoracic pressure
 deformed vena cava reducing preload
Tension Pneumothorax





Severe dyspnea  extreme resp distress
Restlessness, anxiety, agitation
Decreased/absent breath sounds
Worsening or Severe Shock
Cardiovascular collapse




Tachycardia
Weak pulse
Hypotension
Narrow pulse pressure
Tension Pneumothorax

Jugular Vein Distension




absent if also hypovolemic
Hyperresonance to percussion
Subcutaneous emphysema
Late


Tracheal shift away from injured side
Cyanosis
Tension Pneumothorax



Recognize & Manage early
Establish airway
Needle thoracostomy then chest tube
Tension Pneumothorax






Decompress with 14g (lg bore), 2-inch needle
Midclavicular line: 2nd intercostal space
Midaxillary line: 4-5th intercostal space
Go over superior margin of rib to avoid blood vessels
Be careful not to kink or bend needle or catheter
If available, attach a one-way valve
Hemothorax

Most common result of major trauma to the
chest wall



Present in 70 - 80% of penetrating and major nonpenetrating trauma cases
Associated with pneumothorax
Rib fractures are frequent cause
Hemothorax



Each can hold up to 3000 cc of blood
Life-threatening often requiring chest tube and/or
surgery
If assoc. with great vessel or cardiac injury




50% die immediately
25% live five to ten minutes
25% may live 30 minutes or longer
Blood loss results in


Hypovolemia
Decreased ventilation of affected lung
Hemothorax

Accumulation of blood in pleural space





penetrating or blunt lung injury
chest wall vessels
intercostal vessels
myocardium
Massive hemothorax indicates great vessel or
cardiac injury

Intercostal artery can bleed 50 cc/min
Hemothorax

Chest tube, go to OR if

1000 cc out on insertion

200 cc/h for 4 hours
Pulmonary Contusion
 Pathophysiology

Blunt trauma to the chest





Rapid deceleration forces cause lung to strike chest wall
high energy shock wave from explosion
high velocity missile wound
low velocity as with ice pick
Most common injury from blunt thoracic trauma


30-75% of blunt trauma
mortality 14-20%
Pulmonary Contusion

Pathophysiology


Rib Fx in many but not all cases
Alveolar rupture with hemorrhage and edema


increased capillary membrane permeability
Large vascular shunts develop



Gas exchange disturbances
Hypoxemia
Hypercarbia
Pulmonary Contusion
 Assessment Findings





Evidence of blunt chest trauma
Cough and/or Hemoptysis
Apprehension
Cyanosis
CXR changes late
Pulmonary Contusion
 Management




Supportive therapy
Early use of positive pressure ventilation reduces
ventilator therapy duration
Avoid aggressive crystalloid infusion
Severe cases may require ventilator therapy
Myocardial Contusion
Most common blunt injury to heart
 Usually due to steering wheel
 Significant cause of morbidity and mortality
in the blunt trauma patient

Myocardial Contusion
 Pathophysiology


Behaves like acute MI
Hemorrhage with edema



Hemopericardium may occur from lacerated
epicardium


Cellular injury
vascular damage may occur
May produce arrhythmias
hypotension unresponsive to fluid or drug
therapy
Myocardial Contusion




Cardiac arrhythmias following blunt chest
trauma
Angina-like pain unresponsive to nitroglycerin
Precordial discomfort independent of
respiratory movement
Pericardial friction rub (late)
Myocardial Contusion

ECG Changes






Persistent tachycardia
ST elevation, T wave inversion
RBBB
Atrial flutter, Atrial fibrillation
PVCs
PACs
Myocardial Contusion

IV LR/NS


ECG



Cautious fluid administration due to injured myocardium
Standard drug therapy for arrhythmias
12 Lead ECG if time permits
Admit to monitored evironment
Pericardial Tamponade

Incidence





Usually associated with penetrating trauma
Rare in blunt trauma
Occurs in < 2% of chest trauma
GSW wounds have higher mortality than stab wounds
Lower mortality rate if isolated tamponade

Tamponade is hard to diagnose




Hypotension is common in chest trauma
Heart sounds are difficult to hear
Bulging neck veins may be absent if hypovolemia is
present
High index of suspicion is required
Pericardial Tamponade
 Pathophysiology

Space normally filled with 30-50 ml of strawcolored fluid




lubrication
lymphatic discharge
immunologic protection for the heart
Rapid accumulation of blood in the inelastic
pericardium
Pericardial Tamponade

Pathophysiology

Heart is compressed decreasing blood entering
heart



Myocardial perfusion decreased due to



Decreased diastolic expansion and filling
Hindered venous return (preload)
pressure effects on walls of heart
decreased diastolic pressures
Removal of as little as 20 ml of blood may
drastically improve cardiac output
Pericardial Tamponade

Beck’s Triad
Resistant hypotension
 Increased central venous pressure

 distended
neck/arm veins in presence of
decreased arterial BP

Small quiet heart
 decreased
heart sounds
Pericardial Tamponade

Signs and Symptoms


Narrowing pulse pressure
Pulsus paradoxicus
Radial pulse becomes weak or disappears
when patient inhales
 Increased intrathoracic pressure on
inhalation causes blood to be trapped in
lungs temporarily

Pericardial Tamponade
 Management


ECHO if stable to diagnose
In ER –


consider pericardiocentesis
Pericardial window followed by sternotomy in OR
Traumatic Aortic Dissection/Rupture

Caused By:





Motor Vehicle Collisions
Falls from heights
Crushing chest trauma
Animal Kicks
Blunt chest trauma

15% of all blunt trauma deaths
Traumatic Aortic Dissection/Rupture

1 of 6 persons dying in MVC’s has aortic
rupture


85% die instantaneously
10-15% survive to hospital




1/3 die within six hours
1/3 die within 24 hours
1/3 survive 3 days or longer
Must have high index of suspicion
Traumatic Aortic Dissection/Rupture

Separation of the aortic intima and media


Blood enters media through a small intima tear


Tear 2° high speed deceleration at points of relative
fixation
Thinned layer may rupture
Descending aorta at the isthmus distal to left
subclavian artery most common site of rupture

ligamentum arteriosom
Traumatic Aortic Dissection/Rupture
 Assessment Findings





Retrosternal or interscapular pain
Pain in lower back or one leg
Respiratory distress
Asymmetrical arm BPs
Upper extremity hypertension with



Decreased femoral pulses, OR
Absent femoral pulses
Dysphagia
CXR
Work up

CTA



Angio is rarely used
Address other injuries first
Ideally, repaire when stable

Stent vs open
Diaphragmatic Penetration


Suspect intra-abdominal trauma with any injury below
4th ICS
Suspect intrathoracic trauma with any abdominal injury
above umbilicus
Diaphragmatic Rupture
Usually due to blunt trauma but may occur
with penetrating trauma
 Usually life-threatening
 Likely to be associated with other severe
injuries

Diaphragmatic Rupture

Pathophysiology

Compression to abdomen resulting in increased
intra-abdominal pressure





abdominal contents rupture through diaphragm into chest
bowel obstruction and strangulation
restriction of lung expansion
mediastinal shift
90% occur on left side due to protection of right
side by liver
Diaphragmatic Rupture

Assessment Findings

Decreased breath sounds






Usually unilateral
Dullness to percussion
Dyspnea or Respiratory Distress
Scaphoid Abdomen
Usually impossible to hear bowel sounds
Management




suspect
NG tube
CT
Laparoscopy

Sensitive and specific
Esophageal Injury

Penetrating Injury most frequent cause


Rare in blunt trauma
Can perforate spontaneously


violent emesis
carcinoma
Esophageal Injury

Assessment Findings



Pain, local tenderness
Hoarseness, Dysphagia, Respiratory distress
Mediastinal esophageal perforation








mediastinal emphysema / mediastinal crunch
SQ Emphysema
Shock
Abx
resuscitation
Early diagnosis
Gastrographin -> dilute Ba
Repair vs exclude
Tracheobronchial Rupture
 Uncommon injury
less
than 3% of chest trauma
 Occurs with
penetrating or blunt chest trauma
 High mortality rate (>30%)



Respiratory Distress
Obvious SQ emphysema
Hemoptysis


Especially of bright red blood
Signs of tension pneumothorax unresponsive to
needle decompression
Tracheobronchial Rupture




Majority (80%) occur at or near carina
rapid movement of air into pleural space
Tension pneumothorax refractory to needle
decompression
Consider early intubation


intubating right or left mainstem may be life saving
If arrest and suspect air embolysm, may have to do ERT…
Damage control
Damage control principle…
ED Thoractomy




Thoracotomy performed in ER
for resuscitation of patients arriving in extremis
Plan to take to OR afterwards
AIM:




Expeditious control of hemorrhage
Maximization of coronary and cerebral perfusion
Release of pericardial tamponade
Tx of massive air-embolysm
Procedure – Left Anterolateral Thoracotomy
Clamshell Thoracotomy
Release Pericardial Tamponade
Control Intrathoracic Hemorrhage
Eliminate massive air embolism or bronchopleural
fistula





Post intubation & positive pressure ventilation
Get air transfer across traumatic alveolovenous
channels
Pulmonary hilar cross clamping
Air aspirated from L ventricular apex and aortic
root
Cardiac massage
Perform Open Cardiac Massage


Bimanual internal massage with hands in a hinged
clapping motion
Ventricular compression proceeding from apex to base
of heart
Occlude Descending Thoracic Aorta
Futile?


Overall survival ~4-5%
Little to Lose

risk to Health care workers



Risk blood contact
26% trauma pts HIV+ or Hepatitis+
Health care costs
J Trauma. 1998 Jul;45(1):87-94
Selective Application of ED Thoracotomy




Mechanism of Injury
Presence of Vital Signs
Location of Injury
Other Signs of Life
Survival based on mechanism
J Trauma. 1998 Jul;45(1):87-94
Presence of vital signs
J Trauma. 1998 Jul;45(1):87-94
Survival based on organ injured
JACS 2000 Mar;190(3):288-98.
Other Signs of Life (SOL)
JACS 2000 Mar;190(3):288-98.
What about PEA?
26/62 (42%) ED Thoracotomy survivors had PEA requiring CPR
JACS 199:211-215, 2004
Conclusions

ER thoracotomy considered in pts w/:

Presence of vital signs in field or hospital
Better results in penetrating cardiac injury
Results w/ Blunt trauma poor, but survivors exist

PEA after penetrating trauma from stabs




Up to 70% good outcomes
Contraindicated in pts with:

No vital signs, prolonged asystole and unwitnessed arrest/loss of SOL
JACS 199:211-215, 2004
Finally…

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PEA after blunt trauma?
Typically poor outcome, but occasionally will have a
survivor
If CPR > 5 min, contraindicated
References and thanks
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Thank God for internet and Google
several websites specifically:
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http://www.adhb.govt.nz/trauma/presentations/Forums/major%20chest%20inj
uries/sld001.htm
http://www.templejc.edu/dept/ems/Pages/PowerPoint.html
http://www.mssurg.net
www.nordictraumarad.com/Syllabus06/mo%2015/NORDTERpenetrating.pdf
www.iformix.com/spu/chest_trauma.ppt
Greenfield textbook of surgery