Penetrating neck trauma

Penetrating neck trauma

• 1.
  Penetrating neck trauma Tim Martin
• 2.
  Introduction ❖ Anatomy andZones ❖ Hard and soft signs ❖ Resuscitation ❖ Investigation ❖ Management
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  Introduction ❖ Penetrating neckinjuries vs blunt trauma ❖ Injury through the platysma muscle ❖ Mechanisms of injury http://www.innerbody.com/image_musfov/musc18-new.html https://academic.amc.edu/martino/grossanatomy/site/medical/lab%20manual/gastrointestinal/Dissections/Anterior%20Triangle/Anterior%20Triangle1.htm
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  Ballistic injuries ❖ Kineticenergy = mass x velocity squared / 2 ❖ Greater tissue disruption from high mass or velocity projectiles ❖ Yaw ❖ Deformation/Fragmentation
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  Historically ❖ Carotid ligationvs observation ❖ High mortality associated with injury ❖ World War II - exploratory surgery in all patients ❖ High negative exploratory rates - zone based approach ❖ All zone 2 injuries explored, zone 1 + 3 explored based of symptoms due to complications of the surgeries
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  Anatomical approach ❖ Zone1: Clavicle to the cricoid cartilage ❖ Zone 2: Cricoid cartilage to angle of mandible ❖ Zone 3: Above angle of the mandible ❖ Site of external wound vs where projectile passes
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  Structures at risk ❖Vascular - carotid arteries, vertebral arteries, jugular veins ❖ Aerodigestive - larynx/pharynx/trachea, oesophagus ❖ Neurological - Spinal cord ❖ Zone 1 can extend into thorax and include thyroid gland ❖ Zone 2 includes vagus and recurrent laryngeal ❖ Zone 3 includes cranial nerves IX, X, XI and XII
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  Hard and SoftSigns HARD SIGNS SOFT SIGNS Uncontrollable haemorrhage/Shock Haemorrhage responding to fluid resuscitation Expanding or pulsatile haematoma Non pulsatile or expanding haematoma Absent radial pulse Subcutaneous emphysema Thrills/Bruits Dysphonia/Dysphagia Neurological deficit indicating ischaemia Haemoptysis/Haematemesis Respiratory distress/Stridor Visible air bubbles from wound
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  Resuscitation considerations ❖ Catastrophicbleeding ❖ C Spine - consider the mechanism, neurological findings ❖ Immobilised C Spine may make further assessment and observation of penetrating neck injuries difficult ❖ Ramasamy et al 2009 - Review of British soldiers from Iraq war - 56 surviving to surgery, 1 patient unstable C Spine ❖ C Spine fracture from gunshot wound vs stab wound was 1.35% and 0.12% retrospectively: study quoted UpTo date Rhee et al
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  Resuscitation considerations ❖ Airway ❖RSI vs surgical airway ❖ Visible trachae - secure to prevent retraction into thorax ❖ Fiberoptic guided intubation ❖ Specific risks - false lumen out of trachea, exacerbation of injury http://clinicalgate.com/penetrating-neck-trauma/
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  Resuscitation considerations ❖ Breathing- pneumothorax; in cardiac arrest with penetrating neck trauma - thoracotomy ❖ Circulation - fluid/blood resuscitation, pressure ❖ Disability - neurological deficit ❖ Exposure - associated injuries http://resus.me/simple-emergency-haemorrhage-control/
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  Investigation ❖ Bloods andcrossmatch ❖ CXR ❖ Ultrasound ❖ CT with angiography/thin slice helical ❖ Direct visualisation - laryngoscopy/oesophagoscopy
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  Management ❖ Early surgicalconsultation ❖ If hard signs for theatre for exploration ❖ Soft signs - investigate - theatre/observe ❖ Possible surgical approaches: ❖ Zone 1 - median sternotomy ❖ Zone 2 - transverse cervical collar incision ❖ Zone 3 - dislocation/resection of mandible ❖ Endovascular approach
• 14.
  References ❖ Tintinalli’s EmergencyMedicine 8th Edition ❖ UpTo Date Penetrating Neck Injuries: Initial evaluation and management Feb 2017; Kim Newton ❖ Ramasamy et al. Learning lessons from conflict: Pre- hospital cervical spine immobilisation following ballistic neck trauma. Injury. 2009