NECK INJURIES
Yolandé Smit
Perspective
• 5 – 10% of all trauma cases
• 30% associated with injuries outside neck
• Leading cause of immediate death is exsanguination
• Esophageal injuries represents the most frequently missed injury
and may be leading cause of delayed death
• Compound difficulties in evaluation & Mx is the complicated
anatomy - dense concentration of vital structures in a small space
• Ongoing debate : mandatory vs selective exploration
HISTORY
• In 1552, Ambrose Pare ligated CCA.
• WW1 – mortality 60%
• WW11 - mandatory exploration, mortality
47%
• Continuous advances in anaesthesia and perioperative management – mortality 6% for
early vs 35% for late exploration
• Currently 2-6%
Mechanism of Injury
• Penetrating
• Blunt
• Strangulation/ near-hanging
Penetrating Trauma (1)
• 5-10% of all traumatic injuries
• GSW
– High velocity
– Low velocity (50% lower incidence of
significant lesions)
• Stab wounds
• Miscellaneous (shrapnel, impalement)
Penetrating Trauma (2)
Incidence
•
•
•
•
•
•
•
Location
Arterial
Venous
Tracheolaryngeal
Pharyngoesophegeal
Spinal cord
Neuroligical, other
Thoracic duct
Total 1275 patients
Percentage %
12.8
11.3
10.1
9.6
3
3.4
0
Blunt Trauma
• Vascular injuries are rare but represent one of
the most under diagnosed injuries
• Aerodigestive injuries are rare in comparison to
penetrating injuries but can cause acute AW
compromise and delayed complications
• Causes:
–
–
–
–
–
Motor vehicle collisions
‘Clothesline’ injuries
Assault
Strangulation
Sports injuries
Strangulation
• Near hanging
– Complete/judicial
– Incomplete
– Typical
– Atypical
• Manual Strangulation
• Ligature Strangulation
• Postural Strangulation
Strangulation (2)
Pathophysiology
• High cervical fractures, complete cord
transection, death
• Venous congestion with stasis of cerebral blood
flow leading to unconsciousness
• Arterial occlusion with brain injury and death
• Vagal reflexes contribute to fatal dysrythmias
• Pulmonary sequelae
Compression of AW doesn’t play as significant role
in incomplete hanging as does vascular occl
Anatomy
Three components
• Structural
• Visceral collumn
– Respiratory layer
(trachea & larynx)
– Alimentary layer
(pharynx & esophagus)
– Endocrine layer
(thyroid & parathyroid)
• Paired neurovascular
bundle
Anatomy
Two fascial layers
1. Superficial fascia
•
•
Beneath skin
Contains platysma
2. Deep fascia
•
•
•
Investing layer
Visceral layer
Prevertebral
Anatomy
Prevertebral Fascia
• Covers paraspinal
structural components
• Two layers/laminae:
alar & prevertebral
• Fans out to cover
roots of brachial
plexus and subclavian
a
• Axillary sheath
Anatomy
Visceral Fascia
• Forms visceral
compartment
• Pretracheal anteriorly
• Buccopharyngeal and
retroesophageal
posteriorly
• Portion enclosing the
strap muscles a.k.a
middle cervical fascia
• Space between
buccopharyngeal and
prevertebral fascia
Anatomy
Investing fascia
• Envelopes Trapezius
& SCM
• Forms complete
sheath of neck
• Base of skull to
sternum
• Suprasternal space
Anatomy
Carotid Sheath
• Loose aggregation of
connective tissue
• Visceral compartment
medial
• SCM anterolateral
• Prevertebral fascia
posteriorly
Anatomy
Fascial Layers: Importance
• Superficial layer contains
platysma: important
surgical landmark
• Tight fascial
compartments may limit
external hemorrhage from
vascular injuries BUT
easily compromises the
airway
• Danger space:
mediastinits
Anatomy
Three Zones
• ZONE 1- thoracic outlet
– Cricoid cartilage to
sternal notch
• ZONE 2- Central
– Cricoid to angle of
mandible
• ZONE 3 - Skull base
– Angle of mandible to
base of skull
Anatomy
Zones
• Zones apply to neck anterior to
anterior border of trapezius
• Wounds to posterior triangle rarely
associated with vascular, airway or
digestive injury, except vertebral artery
• Wounds through SCM or anterior triangle
have high likelihood of injury
• Decision making for diagnostic tests &
surgical approach
Anatomy
Cervical arteries
Anatomy
Brachiocehalic A
• 4-5 cm in length
• Ascend obliquely to right
of sternoclavicular joint
• Divides into right common
carotid and subclavian aa
Anatomy
Suclavian A
• Passes behind SCM, Jugular vein and
Vagus nerve
• Three branches
• Vertebral
• Internal mammary
• Thyrocervical trunk
• Courses post to anterior scalene than
crosses first rib to become axillary artery
Anatomy
Carotid A
• Common carotid has no branches
• Bifurcates to external and internal carotids
at superior border of thyroid cartilage
• Internal – no cervical branches
• External – 8 branches
Anatomy
Vertebral A
• First branch of subclavian
• Extra-osseous until
entering the transverse
process of C6 (V1)
• Intra-osseous from C6 –
C2 (V2)
• Distal extracranial top of
C2 to base of skull (V3)
INITIAL MANAGEMENT
Initial Management
Airway (1)
Indications for immediate intubation
• Apnoeic or near apnoeic patient
• Comatose patient
• Significant respiratory compromise (stridor,
dysphonic with air hunger)
• Rapidly expanding neck hematoma
• Massive subcutaneous emphysema causing
airway compression or distortion of trachea or
larynx
• Massive bleeding into airway
Initial Management
Airway (2)
‘Wait-and-see’
– If no immediate indication
– Fastidious observation of clinical status
– Equipment readily available
– Prompt intubation if any evidence of
expanding hematoma or enlarging neck
sc emphysema
Initial Management
Airway (3)
• Avoid BMV if possible
• Oral intubation preferred
– Without sedative in unconscious/ flaccid/near
apnoeic patient
– With sedation in uncooperative/agitated pt
– RSI technique-of-choice
– Difficult intubation anticipated:
• ‘Brutane’ technique
• Ketamine 1-2mg/kg IV
Initial Management
Airway (4)
• Surgical airway last resort
• Cricothyrotomy preferred to tracheostomy:
– Time
– Position of neck
– Bleeding
• If laryngeal injury suspected
– Consider awake local tracheostomy
– Cricothyroidotomy for emergencies
– Fibreoptic laryngoscope only if prepared to emergently obtain
surgical airway
• Needle cricothyroidotomy + jet insufflation may be
acceptable to temporize
• Retrograde intubation and blind nasal intubation is
contra-indicated
Initial Management
Airway (5)
Pediatric considerations
• Ideally with RSI
• Fewer AW salvage techniques available:
– Cricothyrotomy contra-indicated under 10
– Emergency tracheostomy difficult
• Degree of AW obstruction after blunt
trauma to larynx inversely related to
degree of calcification, putting children at
highest risk
Initial Management
Control bleeding
• Local pressure
– Proximal and distal control
• Balloon tamponade with Foley’s catheter
– Two catheters in supraclavicular zone1
• Immediate ED thoracotomy with aspiration
of air from RV if cardiac arrest immediately
before or after arrival in ED
Initial Management
Pitfalls
• Do not probe wounds
– Platysma penetration mandates evaluation in
controlled fashion
• Controversy about NGT
– Tube may migrate from esophagus
– Valsalva by patient may dislodge clot
– Bloodstained
Initial Management
Immediate Surgical Exploration
•
•
•
•
•
INDICATIONS
Severe active bleeding
Shock not responding to fluids
Rapidly expanding hematoma
Absent radial pulse
Evolving stroke
Initial Management
Complete Primary Survey
• Thorough examination
– Vascular: Hard signs of vascular injury
– Airway: Stridor hoarseness, dyspnoea, sc
emhysema
Initial Management
Secondary survey
• Digestive tract
– Dysphagia
– Odynophagia
– Hematemesis
– Subcutaneous emphysema
• Neurological: focal signs
Further Management
Further Management
• If no indication for immediate surgical
exploration, subsequent intervention
based on :
– clinical exam
• Hard signs
• Soft signs
• No symptoms or signs
– diagnostic testing
Hard Signs
•
•
•
•
•
Pulsatile bleeding
Expanding hematoma
Not responding to resus
Absent distal pulses
Distal signs
– Cold, pale limb
– Stroke
• Bruit
• Airway obstruction
Soft signs
•
•
•
•
•
•
•
•
Venous bleeding
Stable hematoma
Responding to resus
Diminished peripheral pulses
Proximity to major artery
Peripheral nerve deficit (brachial plexus)
Hemoptysis/hematemesis
Dysphonia/dysphagia
Diagnostic Strategies
•
•
•
•
•
•
•
Stable patient with hard signs:
exploration (diagnostic strategies to plan)
Stable patient with soft signs/ asymptomatic:
mandatory vs selective exploration (diagnostic
strategies to aid in diagnosis)
Is physical examination reliable?
Consider:
Resources
Potential for injury
Ability to serially exam
Consequences of missed injury
Diagnostic strategies
• X-Rays
– Chest: PT/HT, widened mediastinum, mediastinal air,
elevated hemidiaphragm, FB
– Neck: prevertebral air or swelling, sc air, FB
• Gastrograffin swallow
– All penetrating neck injuries due to high incidence of
occult injuries
• Endoscopy
– If swallow (-), enhances sensitivity for penetrating
esophageal injury
Diagnostic Strategies
• Arteriogram
– Diagnostic
– To plan surgery
– Therapeutic
• Laryngoscopy/ bronchoscopy
– Hemoptysis/ hoarseness/ sc emphysema/ laryngeal
tenderness or deformity
• CT neck
– Useful for evaluating laryngeal injuries
– May play a role in the future as screening modality in
diagnostic evaluation of AW & vascular injuries in
asymptomatic pt
Diagnostic strategies
Airway/resus/assessment
Stable
Unstable
Active hemorrhage
Zone 1
Zone 2
Zone 3
Expanding
hematoma
Swallow
Evolving stroke
Arteriogram
Endoscopy
Swallow
Explore
Arteriogram
+
Endoscopy
-
Observe
+
Explore
Embolize
Observe