Prepared by
Dr.Hiwa As’ad



As the incidence of violence rises in the
society the rate of penetrating head &neck
trauma also increase
5-10 % of all trauma cases
potentially dangerous & require emergency
treatment
There are four groups of vital structures
which are vulnerable to injury in a small
anatomical area & are not protected by bone:
1-Air passages including (Pharynx, Larynx,
trachea & lungs)
2-Vascular ( Carotid ,Jugular, Subclavian,
Innomenate, Aortic arches)
3-Gastrointestinal tract ( Pharynx, esophagus)
4-Neurologic structures (Spinal cord ,brachial
plexus ,cranial nerve ,peripheral nerve)

Air way
1-Strider
2-Cyanosis
3-Respiratory distress
4-Hemoptysis
5-Hoarsness
6-Tracheal deviation
7-Surgical emphysema
8-Sucking wounds

Vascular system
1-Hematoma
2-Persistant bleeding
3-Neurologic deficit
4-Absent pulse
5-Hypovolemic shock
6-Thril
7-Bruit
8-Change of sensorium

Neurologic
1-Hemiplegia
2-Quadreplegia
3-Coma
4-Crainal nerve deficit
5-Change of sensorium

Esophagus & Hypo-pharynx
1- Dysphagia
2-Odenophagia
3-Subcunatous emphysema
4-Hematamesis
5-Hemoptysis
6-Tachycardia
7-Fever




The most important is
the initial evaluation and
resuscitation performed
in the emergency
department.
The protocol is based
on a primary and
secondary survey
approach
This treatment can be
divided into four
categories—primary
survey, resuscitation,
secondary survey, and
definitive care.
1-Airway





Establishment of the airway.
The oropharynx, larynx, and trachea can be
obstructed by secretions, blood, and foreign
bodies.
Collapse of the oropharyngeal airway can occur
with loss of consciousness and from facial
fractures.
Direct trauma to the larynx and trachea may
cause airway obstruction below the oropharynx.
Maneuvers range from positioning,manual
cleaning of the oropharynx followed by
suctioning of secretions to surgical procedures.



There is risk of an occult
cervical spinal fracture. The
airway must be controlled with
the assumption that such a
fracture exists and the neck
must be completely immobilized
in a neutral position.
Maintain manual stabilization of
the head and avoid
hyperextension by holding the
cervical spine with the hands
while immobilizing the head with
the forearms
Traction on the head is avoided,
because distraction with further
injury to the spinal cord can
occur if the patient has an
unstable cervical spinal injury.

Once the neck of
an unconscious
patient has been
secured, forward
traction of the
mandible is
performed to
overcome
pharyngeal collapse

Once the airway has
been established
and the patient is
spontaneously
breathing,
supplemental
oxygen can be
provided through
nasal prongs or a
face mask.
In sever cases more aggressive airway
management is needed:
1.Nasotracheal intubation for establishing an
airway in a conscious patient who may have a
cervical spinal injury because it can be done
without excessive mobility of the neck and is
better tolerated by an awake patient than is
orotracheal intubation

2.orotracheal intubation:
 In ideal circumstances, a lateral cervical spine
radiograph is obtained before orotracheal intubation
to evaluate for a possible cervical spinal fracture.
 Bag-mask intubation can be an effective method of
maintaining the airway until radiographs are
obtained.
 If the patient is unconscious and cervical spinal
injury has been ruled out, orotracheal intubation can
be readily accomplished.
 A patient who is awake must be paralyzed with
succinylcholine for successful orotracheal intubation.


After intubation, the chest is auscultated to
ensure that the tube is in the trachea and not
in the esophagus or in one of the mainstem
bronchi.
If an endotracheal tube cannot be inserted, as
when a patient has major facial fractures or
has sustained laryngotracheal trauma,
surgical airway intervention may be needed.
There are four surgical methods of obtaining
an airway
1-Needle cricothyrotomy,
2-Conventional cricothyrotomy,
3-Tracheotomy, and
4-Percutaneous transtracheal ventilation.






For children is the best procedure.
performed by placing a no. 12 or no. 14
intravenous cannula with a plastic sheath through
the crico-thyroid membrane into the tracheal
lumen.
Once in the airway, the needle is withdrawn and
the plastic sheath is advanced.
When properly positioned, the sheath is connected
to bottled oxygen.
Patients can be maintained for up to 30 minutes
with this technique.



The preferred approach for
adult patients.
It consists of a small
vertical skin incision over
the area of the cricothyroid
membrane followed by a
horizontal incision through
the cricothyroid membrane
itself.
The blunt end of the
scalpel is inserted between
the cricoid and the thyroid
cartilages and rotated 90
degrees to make an
opening through which an
endotracheal tube or
tracheostomy tube can be
inserted.


For patients with laryngeal trauma, tracheal
trauma, or tracheal disruption,
cricothyrotomy is inadvisable, and emergency
tracheotomy is performed.
Percutaneous transtracheal ventilation, a
technique similar to needle cricothyrotomy, is
an acceptable alternative in the treatment of
these patients.

Continuous monitoring of oxygenation with
pulse oximetry is extremely helpful in
determining the adequacy of oxygenation of
a trauma patient and is used in the care of all
critically injured patients to allow early
detection of arterial oxygen desaturation.
The secondary survey consists of a detailed physical
examination with the patient fully exposed (from head to
toe).
It is undertaken once the lifesaving priorities of the
primary survey have been done.
The breadth and speed of this examination depend on the
patient's injuries and the need for definitive surgical
intervention.
 history: including the mechanism of injury, preexisting
medical problems, current medications, known drug
allergies, and when the patient last ate.
 Routine investigations: including a complete blood cell
count, chest radiography, and urinalysis.
 If drug overdose or alcohol consumption is suspected,
toxicological studies can be performed.
 Hypotension warrants blood typing and cross-matching.


X-rays required after
secondary survey are
now completed
Special investigations
such as Angiography
,CT scan, US,
gastrograffin /Barium
studies may now be
performed in
hemodynamically
stable pt.
Penetrating injury
1-Stabs
2-Gun shot wounds
*Low velocity
*High velocity
*Shotgun
 Blast
 Blunt

• If platysma muscle is penetrated or not .
• Although overall uncommon, Pharyngoesophageal injury is the most commonly
missed injury to the neck


Some authors advocate routine exploration of
all injuries penetrating the platysma.
Others advocate observation and selective
exploration based on preoperative
arteriographic findings and on the presence
or absence of symptoms that suggest
vascular, airway, and neurologic injury.

Zone I: sternal notch to cricoid cartilage

Zone II: cricoid cartilage to angle of mandible

Zone III: angle of mandible to base of skull
Patients in unstable condition with active hemorrhage need
surgical exploration.
If the patient is stable:

Penetrating injuries to (zone I) ; are examined by arteriography,
laryngoscopy, and esophagoscopy or a barium swallow .

Penetrating injuries to(zone III) are examined with
arteriography to exclude carotid or vertebral artery injury.

Penetrating injuries to (zone II) are examined by routine
exploration or combinations of arteriography, laryngoscopy, and
esophageal evaluation if the injury has penetrated the platysma.
• High risk of injury to great vessels, trachea
,esophagus and lungs
• Difficult region for exposure and control
• Management: arteriography of arch, great
vessels, carotids, and vertebral (may also be
used for balloon occlusion for temporary
preoperative control);
 Esophagogram with esophagoscopy, direct
laryngoscopy, and bronchoscopy
• High risk of injury to carotid sheath (carotid artery, internal
jugular vein) and aerodigestive system.
• More easily accessible and more easy to control
• Management
1.Selective Management: arteriography, esophagram with
esophagoscopy, direct laryngoscopy, and bronchoscopy
2.Mandatory Surgical Exploration: gunshot wounds that cross
midline, obvious serious injury (strider, active hemorrhage,
absent carotid pulse), active bleeding, air bubbling through
wound, arteriography not available, intoxicated patient
3.Elective Surgical Exploration: more accurate than diagnostic
tests, up to 50–70% of elective neck explorations are negative
• High risk of injury to distal carotid artery,
parotid gland, and pharynx
• Difficult region for exposure and control
• Management: arteriography (balloon
occlusion),
 Esophagram and direct laryngoscopy
Pharyngeal injuries
Suspected in zone II penetrating injury if the pt has dysphagia,
odynophagia, subcutaneous emphysema ,hemoptysis, &
hoarseness.
 Diagnosis:
1-Flexible nasopharyngoscopy: edema ,bleeding or perforation
2-Direct phayngscopy: reveals all injuries.
3-Esophagography: unreliable tool
 Treatment
1- Naso & oro pharynx managed conservatively as it’s capacious
& has low intra-luminal pressure
2-Hypopharynx managed like esophageal injury by exploration for
it’s high intra-luminal pressure & less capacious


Suspected in pt with Zone I & II injuries with
hoarseness, neck pain, and crepitus.
Fiberoptic examination and C/T scans are
extremely helpful.
1-Fiberoptic Nasopharyngoscopy
 It is well-tolerated in a patient who is awake and
is a quick diagnostic test
 The larynx is evaluated for vocal cord mobility,
arytenoids symmetry and extent of the injury
from minor edema or hematoma to more severe
soft-tissue tears and exposed cartilage.
2-Conventional X-Rays and Soft-Tissue Films
 Plain-film x-rays of the chest and soft-tissue
neck films continue to be essential components
in patient evaluation.



The best radiographic tool
available to evaluate
laryngeal trauma .
Helpful when the
examination is normal but
there is a high index of
suspicion for occult
laryngeal injury where It may
reveal a subtle fracture that
requires fixation or it may
obviate the need for rigid
endoscopy if the scanned
image is completely normal.
To plan the operative
procedure in a patient with a
controlled and stable airway.

Laryngeal injuries are grouped according to increasing severity:
1- Patients with Group I injuries have minor endolaryngeal hematomas or
lacerations. These patients are treated conservatively
2- Group II injuries demonstrate airway compromise, more severe soft tissue
injury, or single nondisplaced laryngeal fractures. These patients are usually
managed with a tracheotomy followed by direct laryngoscopy

If an arytenoid dislocation is discovered, then closed reduction should be
attempted.
3-Group III injuries include patients with massive edema, mucosal tears with
exposed cartilage, displaced fractures, or vocal cord immobility.
4-Group IV describes the unstable larynx with comminuted fractures.
5-Group V classification is the most severe type of injury; these patients present
with complete laryngotracheal separation.


Injuries within Groups III–V require immediate operative repair.
The ability to restore the integrity of the larynx impacts a patient's long-term
outcome with regard to voice, airway, and the quality of life.
The common carotid artery is the most frequently injured accounting
for 22%of vascular injuries hard signs includes ,hematoma persistent
bleeding ,neurologic deficit absent pulse ,thrill & bruit.
Investigation for Zone I & III is recommended because of difficult
assessment clinically but Zone II clinical assessment is reliable
Diagnostic tools
Angiograghy
Is gold standard & has the following benefit
 Identification of the site of injury
 Detection of subclinical vascular injury
 Providing a road map for surgeon
 Giving idea about the circle of Willis
Treatment
Vascular surgical intervention (Repair or Ligation)


External jugular vein can be safely ligated
Unilaterally internal jugular vein can be
ligated
Bilateral internal jugular vein injury:
Repair
(loss of consciousness, increase intracranial
pressure &even death might occur after
bilateral ligation).

brachial plexus injury :
repaired electively within 24-72 hours unless
the neck explored for other reasons.
