NECK TRAUMA

General Surgery II Lecture 2 Triangles of the Neck

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III-B USTFMS
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NECK TRAUMA

• 5-6% as isolated injury

• Fatality rates:
– stab wounds
1-2%
– gunshot wounds
5-12%
– rifle/shotgun
50%
Anatomy of the Neck
– preventable deaths
50%

Causes of Neck Trauma

• Blunt Trauma
• Diving injuries
• Assault
• Vehicular
– crashing into windshield
/steering wheel
– seat belt
– whiplash ZONES OF THE NECK
– “clothesline” [MONZON]
• Penetrating
– Assault
• stab wounds
• gunshot wounds
– Vehicular
• broken glass

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 • avoid intubation in
Zones of the Neck symptomatic/ high risk
• Neurologic injury

Penetrating Neck Trauma

• 70 - 80% of injuries
• vascular/aerodigestive tract
injury
• Hemorrhage
– 20-30%
• Mortality
– 5-6 %

Signs of Significant Injury in

Penetrating Neck Trauma
VASCULAR INJURY
• Shock
• Active bleeding
• Large/expanding hematoma
• Pulse deficit

AIRWAY INJURY
• Dyspnea
• Stridor
• Hoarseness
• Dysphonia or voice change
• Subcutaneous emphysema
• Zone I
DIGESTIVE TRACT INJURY
• highest mortality
• Hemoptysis
• Zone II • Dysphagia/odynophagia
• most frequent site of • Hematemesis
injury • Subcutaneous emphysema
• lower mortality
• Zone III
Injured Structures from Penetrating
• neurological Neck Wounds
• distal carotids • SYSTEM INJURED
• pharyngeal injuries PATIENTS(%)
• Arterial
Blunt Neck Trauma 516 (12.3)
• Venous 769
• Frequently involves C5-C6 (18.3)
• Rescue/ transport • Digestive
• neck immobilization 354 ( 8.4)

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 • Respiratory 331 ( 7.8)
• Source: Adapted from JA
Asensio, et al. Management of
Penetrating Neck Injuries: The
Controversy Surrounding Zone II
Injuries In JA Asensio and JA
Weigelt (eds.), The Surgical
Clinics of North America
Contemporary Problems in
Trauma Surgery. 71:2, 1991;
Initial Care
• ABCs of Trauma Resuscitation
– ventilation
– treatment of shock
– baseline neurologic exam
Airway Assessment
• Spontaneous respiration
– conscious
– stridor
– tachypnea
– dyspnea
– frothing
• No respiration
– intubate
– airway obstruction
– shock
Hemorrhage/ Shock
• Control bleeding
– direct digital pressure
– occult bleeding
• hemothorax -
CTT
• Venous access
– fluid replacement/ blood
– central line
History/ Physical Exam
– Time factor
– Manner of injury
– Pre-existing disease
– Vital signs
– location/
– extent of injury
– neurologic deficit
– ? probing
Penetrating Neck Trauma Algorithm
Presentation
• - GSW, POE: L supraclavicular,
No POX, Hemorrhagic shock
• - hacking wound to the neck with
external bleeding; shock
• - punctured wound to the neck,
stable vital signs
• - punctured wound to the neck.
stable VS, suddenly develops
dyspnea
• - 1.5 cm stab wound zone II,
stable vital signs with
subcutaneous emphysema
• - punctured wound,nape, in
hypovolemic shock, unable to
move or feel LLE
Mandatory Exploration
– negligible m/m for (-)
exploration
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 – comparative cost of • more in Zones I
work-up and III
– 17-25% (+) exploration in • Esophagography
asymptomatic patients • water soluble/
• 83% significant barium contrast
injury in • 50-90%
transcervical sensitivity
gunshot wounds • Esophagoscopy
– high mortality for delayed • 50-90%
operations: sensitivity
• 67% for vascular • rigid / flexible
injury Surgical Management
• 44% for • Vascular injuries
esophageal injury – Carotid Artery
• blunt injury - 20-
Selective Exploration 40% mortality
– 40-60% incidence of • permanent
negative exploration neurologic
– medical cost of impairment in 40-
unnecessary surgery 60%
– availability of accurate, • repair or ligation
non-invasive diagnostic of penetrating
facilities lacerations
– mandatory exploration – comatose
based on high velocity patients
military injuries – acute
stroke
Rules on Exploration after
– All symptomatic patients revasculari
are explored zation
– Work-up is irrelevant in • Vertebral artery
the presence of clinical • hyperextension/rot
signs of injury ation
– Zone I injuries liberally • chiropractic
explored manipulation
• difficult vascular • soccer/volleyball
control injury
• disastrous • heavy metal rock
consequences music
with delay – Usually diagnosed
angiographically
– thrombosis/hemorrhage
Diagnostic work-up
• Angiography Esophagus
• gold standard for – Difficult diagnosis
vascular injury

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 • clinically evident
in 20-30%
• exponential
increase in MR
with late
diagnosis, 100% if
undiagnosed
– Primary repair when
feasible
– cutaneous
pharyngostomy/
esophagostomy

Larynx and Trachea

– Subcutaneous
emphysema,
hoarseness,respiratory
distress
– debridement
– reduction of fractures
– coverage of exposed
cartilage
– closure of tracheal defects
– tracheostomy
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