Neck Trauma Penetrating trauma Blunt trauma Near Hanging
Neck Trauma
§ Penetrating trauma § Blunt trauma § Near - Hanging & Strangulation 2
Penetrating Trauma Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation 3
Pathophysiology Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous 4
Organ System Classification § § Vascular ( most common ) Pharyngoesophageal Laryngotracheal Others ( cranial nerve, thoracic duct, brachial plexus, spinal cord…. 5
Vascular Three pathophysiologic mechanisms § External hemorrhage § Extending soft tissue hematoma, distort or obstruct the airway § Disruption of cerebral perfusion ( CVA ) 6
Pharyngoesophageal § Rarely causes any immediate consequence § Delayed diagnosis can lead to serious soft tissue infection, mediastinitis and sepsis 7
Laryngotracheal § Small puncture wound § Airflow away from respiratory tree § Obstruction of airway 8
Wound Location Classification § Anterior § Posterior § Anterior l l l (Sternocleidomastoid muscle ) Zone 1 ( below cricoid cartilage ) Zone 2 ( between the cricoid cartilage and mandible angle ) Zone 3 ( above mandible angle ) 9
Management of Penetrating Trauma Stabilization § Critically injured patient l Rapidly assessing vital functions and the area of injury Performing stabilizing interventions Initiating a diagnostic workup Definitive care l Violates the platysma ( explore at OR ) l l l § No immediate life threat * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order 10
Airway § The risk of spinal cord injury is minimal § Cervical cord injury in a gunshot wound victim when intubation has never been reported § Preintubation radiography is significant 11
Airway General § Most difficult management dilemma: awake patient with impending airway obstruction § Preoxygenation is important # Comatous patients & patients in respiratory distress require immediate intubation # It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED ) 12
Airway Method § Oral & nasal intubation with or without endoscopic guidance or muscle relaxants § Percutaneous transtracheal ventilation ( PTV ) § Surgical airway 13
Airway Method § PVT l l l Airway remains unprotected & uncomfortable in conscious patient Temporary intervention Complication and contraindication 1. Significant airway obstruction & penetrated airway 2. Subcutaneous emphysema, pneumothorax 14
Airway Method § Surgical Airway l l l Last resort ( direct injury to the airway is exception ) cricothyrotomy Tracheostomy or even intubation via the wound 15
Hemorrhage External hemorrhage § Direct pressure § Blindly clamping bleeding vessels is avoided § Quick transfer to the operating room Inter Hemorrhage § Airway compromised § Zone 1 injury result in hemothorax ( thoracostomy ) 16
Definitive Management of Penetrating Trauma Unstable patient Immediate transfer to the OR Stable patient l l l General Mandatory exploration Selective Approach 17
Definitive Management Stable Patient § General l l Lateral neck film CXR ( especially in zone 1 injuries ) NG tube should not be inserted Prophylactic antibiotics § Mandatory exploration § Selective Approach l A selective method reserves operative intervention for patients with clinical signs of significant injury 18
Clinical Findings: Require Surgical Intervention Using a Selective Approach § § § § § Expanding or pulsatile hematoma Presence of a bruit Horner syndrome Subcutaneous emphysema Air bubbling through wound Hemoptysis or blood - tinged saliva Shock or active bleeding Absent peripheral pulses Respiratory distress Others are observed & undergo various 19 diagnostic studies
Other Diagnostic Studies § § Bronchoscopy Esophagography Esophagoscopy Angiography # Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies 20
Disposition of Penetrating Neck Trauma No indication for surgery ==> admission for at least 24 hrs 21
Blunt Trauma § Rare, compared with penetrating trauma § Motor vehicle crash or an assault § Off - road vehicles 22
Classification of injuries § Larygotracheal § Pharyngoesophageal § Vascular : delayed dissection or thrombosis ( CVA ) 23
Four recognized mechanisms by which thrombosis can occur § A direct blow to the neck § A blow to the head that causes hyperextension and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels § Blunt intraoral trauma § Basilar skull fracture 24
Spinal column and spinal cord injuries are more prevalent in blunt trauma 25
Clinical Feature Physical findings may be lacking , it is important to elicit symptoms 1. Dysphagia, odynophagia 2. Voice quality 3. Aphonia, muffled voice ( serious injury ) 26
Management of Blunt Neck Trauma Whether the patient has laryngotracheal injury? 27
Definitive Management General C - spine X-ray l CXR l Additional Studies Laryngotracheal l Vascular l Pharyngoesophageal l 28
Additional Studies § Laryngotracheal Plain radiographs l CT l endoscopy ( fiberoptic bronchoscopy ) ( Consult chest surgeon or ENT ? ) l § Vascular l l Angiography Color Flow Doppler ultrasound § Pharyngoesophageal Threshold for performing diagnostic studies should be low l Esophagram & esophagoscope ( Consult chest surgeon ) 29 l
Disposition of Blunt Neck Trauma § Laryngeal injuries do not require immediate repair § Tracheal injuries should receive prompt surgical attention 30
Near - Hanging & Strangulation Classification of Strangulation § Hanging ( most common ) § Ligature strangulation § Manual strangulation § Postural strangulation 31
Clinical Features § Superficial & Deep Neck § Respiratory (delayed mortality) l l Bronchopneumonia Aspiration pneumonitis Delayed airway obstruction ARDS § Neuro psychiatric 32
Management § Spinal cord injury is very rare § Phenytoin: useful in preventing ischemic cerebral damage § Naloxone § Ca 2+ channel blocker 33
Summary Structured approach to these patients, regardless of mechanism is essential to optimize outcome & avoid catastrophe 34
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