Neck trauma

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management of neck trauma

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Neck trauma

  1. 1. Neck trauma<br />Done by:<br />Dr. ahmad m. aldhafeeri<br />R1. ORL-H&N surgery<br />1<br />
  2. 2. 2<br />dr.ahmad aldhafeeri<br />
  3. 3. 3<br />dr.ahmad aldhafeeri<br />
  4. 4. Type of neck injury <br />- Penetrating<br />Gunshot wound<br />Stab wound<br />- Blunt<br />MVA<br />Sport injury<br />Strangulation<br />Blows<br />4<br />dr.ahmad aldhafeeri<br />
  5. 5. 5<br />dr.ahmad aldhafeeri<br />
  6. 6. Zone III<br /><ul><li> Zone II
  7. 7. Zone I</li></ul>6<br />dr.ahmad aldhafeeri<br />
  8. 8. ۞ Zone I <br /> ۞ Bound superiorly by the cricoid and<br /> inferiorly by the sternum and clavicles<br />- The great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, and jugular veins), <br />- Aortic arch <br />- Trachea <br />- Esophagus <br />- Lung apices <br />7<br />dr.ahmad aldhafeeri<br />
  9. 9. ۞ZONE II<br /> ۞Bound inferiorly by the cricoid and superiorly by the angle of the mandible<br />- Carotid and vertebral arteries <br />- Jugular veins <br />- Pharynx, Larynx, Trachea <br />- Esophagus, base of the tunge<br />- Phrenic , vagus , and hypoglossal nerves<br />۩ Injuries here are seldom occult<br />۩ Common site of carotid injury<br />8<br />dr.ahmad aldhafeeri<br />
  10. 10. ۞ZONE III<br /> ۞ Lies above the angle of the mandible<br />- Carotid arteries <br />- Jugular veins <br />- The salivary and parotid glands <br />- Esophagus, pharynx <br /><ul><li>Major cranial nerves </li></ul>۩ Vascular and cranial nerve injuries common<br />9<br />dr.ahmad aldhafeeri<br />
  11. 11. morbidity and mortality<br />Zone I injuries are associated with the highest morbidity and mortality rates.<br />more common among males than females.<br />Most are adolescents and young adults<br />10<br />dr.ahmad aldhafeeri<br />
  12. 12. Neck trauma accounts for 5-10% of all serious traumatic injuries<br />missed cervical injuries secondary to neck trauma result in a mortality rate of greater than 15%. <br />10% of neck wounds lead to respiratory compromise. Loss of the airway patency may occur precipitously, resulting in mortality rates as high as 33%.<br />11<br />dr.ahmad aldhafeeri<br />
  13. 13. Frequancy<br />Thrombosis is the most common complication of vessel injury, occurring in 25-40% <br />the most common sites of vascular injuries internal jugular vein (9%) and carotid artery (7%). <br />Injury to the pharynx or the esophagus occurs in 5-15% of cases. <br />The larynx or the trachea is injured in 4-12% of cases. <br />Major nerve injury occurs in 3-8% of patients sustaining penetrating neck trauma.<br />12<br />dr.ahmad aldhafeeri<br />
  14. 14. Vascular injury<br />Hard evidence:<br />sever active hemorrhage, shock unresponsive to volume expansion, absent ipsilateral upper extremity, neurologic deficit<br />Soft evidence:<br /> bruit, widened mediastinum , hematoma<br />Decreased upper extremity pulse, shock response to volume expansion<br />13<br />dr.ahmad aldhafeeri<br />
  15. 15. Laryngotracheal injury <br />Subcutaneous emphysema<br />Airway obstruction<br />Sucking wound<br />Stridor<br />Dyspnea<br />Hemoptysis<br />Hoarseness<br />Dysphonia <br />14<br />dr.ahmad aldhafeeri<br />
  16. 16. Pharynx/esophagus injury <br />Subcutaneous emphysema, <br />Hematemesis <br />Dysphagia <br />Odynophagia <br />15<br />dr.ahmad aldhafeeri<br />
  17. 17. Approach <br />&<br />Management<br />16<br />dr.ahmad aldhafeeri<br />
  18. 18. Airway<br />Breathing<br />Intubation vs. Surgical Airway<br />Circulation<br />IV access, Immediate Exploration<br />disability<br />exposure<br />Primary survey<br />17<br />dr.ahmad aldhafeeri<br />
  19. 19. Established Airway<br />be prepared to obtain an airway emergently<br />intubation or cricothyrotomy<br />Be a ware of cutting the neck in the region of the hematoma -- disruption there may lead to massive bleeding<br />must assume cervical spine injury until proven otherwise<br />18<br />Airway<br />dr.ahmad aldhafeeri<br />
  20. 20. Zone I injuries with concomitant thoracic injuries<br />pneumothorax<br />hemopneumothorax<br />tension pneumothorax<br />19<br />Breathing<br />dr.ahmad aldhafeeri<br />
  21. 21. Bleeding should be controlled by pressure<br />Do not clamp blindly or probe the wound depths<br />The absence of visible hemorrhage does not rule out<br />Two large bore IVs<br />Careful of IV in arm unilateral to subclavian injury<br />Do not remove objects protruding from the neck in the ER<br />20<br />Circulation<br />dr.ahmad aldhafeeri<br />
  22. 22. Cross-match, hematologic analysis, chemistries, urinalysis, coagulation profile, blood gas, toxicologic analysis<br />B-hCG for female <br />Urine cath.<br />CXR – inspiratory /expiratory films to assess the lung, mediastinum and any phrenic nerve injury<br />Cervical spine film to rule out fractures<br />Soft tissue neck films AP and Lateral<br />Arteriograms, contrast studies as indicated<br />21<br />dr.ahmad aldhafeeri<br />
  23. 23. Obtain from any witnesses or patient<br />Mechanisms of injury - stab wounds, gunshot wound, high-energy, low-energy, trajectory of stab<br />Estimate of blood loss at scene<br />Any associated thoracic, abdominal, extremity injuries <br />Neurologic history<br />22<br />Secondary survey<br />history<br />dr.ahmad aldhafeeri<br />
  24. 24. Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits<br />Neuro exam: mental status, cranial nerves, and spinal column<br />Examine the chest, abdomen, and extremities<br />Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here<br />Don’t blindly explore wound or clamp vessel<br />23<br />examination<br />dr.ahmad aldhafeeri<br />
  25. 25. 24<br />dr.ahmad aldhafeeri<br />
  26. 26. Zone I<br />Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy<br /> suspicion must be great before taking the patient to OR becausehigh mortality rate.<br />Cardiothoracic surgery consultation a must<br />4 vessel Angiography is advocated by surgeon because difficulty of identify injury intraoperative<br />2 prospective study show only 5% of zone I injury need operation <br />25<br />dr.ahmad aldhafeeri<br />
  27. 27. Zone II<br />Few injuries will escape clinical examination <br />Most carotid injuries occur here<br />algoriyhm<br />*Several study have suggest of contrast enhance CT to demonstrate the injury and aid for further invasive investigation or exploration<br />*Furthermore studies shown CT angio. More to be useful and comparable to conventional angiography in evaluation vascular inj.<br />26<br />dr.ahmad aldhafeeri<br />
  28. 28. *Finally some expert recommend ipsilateral exploration despite increase incidence of negative exploration and increase hospital cost <br />None of these algorithm for management of penetrating zone II had shown superiority over the others* <br />27<br />dr.ahmad aldhafeeri<br />
  29. 29. Zone III<br />Upper neck injury with evidence of vascular injury required prompt CT angiography<br />Embolotherapy can be used for temporary or definitive managementexcept for Ica<br />Direct pharyngoscopy suffice to exclude aerodigestive trauma<br />Endovascular stenting or embolization especially in zone I & III should be considered<br />28<br />dr.ahmad aldhafeeri<br />
  30. 30. Exploration vs. Observation<br />Many experts have adopted a policy of selective exploration<br />Decreased number of negative explorations, increased number of positive explorations<br />Decreased cost of medical care, maybe<br />No increase in mortality when adjunctive diagnostic studies and serial exams performed<br />29<br />dr.ahmad aldhafeeri<br />
  31. 31. *Exploration <br />Most common approach in anterior of SCM<br />Collar incision is reversed for isolated aerodigestive inj. Or for bilateral exploration <br />Major arteries should be repaired where possible except the vertebral which can be ligated<br />Veins can be ligated EXCEPT bilateral IJV<br />30<br />dr.ahmad aldhafeeri<br />
  32. 32. Partial lacerations can be closed primarily -- vein patches will help prevent subsequent stenosis<br />High velocity wounds produce a surrounding area of contusion which may be thrombogenic and which must be resected; then primary reanastamosis if possible<br />31<br />dr.ahmad aldhafeeri<br />
  33. 33. Aerodigestive injury in EXPLORATION<br />DL where laryngeal injury is suspected<br />Aerodigestive should repaired primary by synthetic absorbable suture<br />IF tandem injury occur a well vascularized flap should be interpose between the repairs to prevent aerodigestive fistula <br />32<br />dr.ahmad aldhafeeri<br />
  34. 34. Drain-if suspect aerodigestive injury <br />To Prevent lethal mediastinitis<br />and In combined aerodigestive and vascular injuries the aerodigestive repair should be drained to the contralateral neck to prevent break down of the vascular repair from gastrointestinal secretion <br />raw surfaces Cover with nasal, buccal, or local mucosal flap<br />A keel or soft stent is placed when loss areas are opposed<br />33<br />dr.ahmad aldhafeeri<br />
  35. 35. In central neurologic deficits:<br />repair the artery when there are minimal deficits, with gross deficits restoration of flow can convert ischemic infarcts into hemorrhagic ones -- the artery should be ligated<br />a deterioration in neurologic status dictates arteriography and reexploration<br />EC-IC bypass when irreparable injury to ICA<br />34<br />dr.ahmad aldhafeeri<br />
  36. 36. Blunt neck trauma<br />Sever Blunt neck trauma can result in significant laryngeal and vascular injury<br />Best modality in stable pt contrast enhance CT to demonstrate the injury and aid for further invasive investigation or exploration<br />35<br />dr.ahmad aldhafeeri<br />
  37. 37. laryngeal injury<br />If suspect of minor laryngeal injury can treated with airway protection, head of bed elevation and possibly antibiotics<br />Major laryngeal injury required operative exploration and repaired <br />36<br />dr.ahmad aldhafeeri<br />
  38. 38. Blunt vascular injury<br />Usually involves the internal and common carotid artery <br />there may also be injury to the vertebral vessels without symptomatology & come later with neurological deficit <br />Four vessels angiography and CT angiography are preferred diagnostic modalities<br />Severity of the deficits and time of diagnosis are strongly associated with outcome<br />37<br />dr.ahmad aldhafeeri<br />
  39. 39. The current recommendation is for operative repair for surgically accessible lesions.<br />Systemic Anticoagulant with heparin appears to improve neurologic outcome and is therefore recommended for surgically inaccessible lesions<br />38<br />dr.ahmad aldhafeeri<br />
  40. 40. If suspect esophagial injury <br />ESOPHAGOSCOPY /ESOPHAGOGRAM<br />If +ve operation exploration ‘ll next step<br />39<br />dr.ahmad aldhafeeri<br />
  41. 41. Conclusions: <br />Maintain a healthy respect for apparently minor neck wounds because of potential fatal outcome for initially benign appearing injuries<br />Do not try to infer trajectories of gunshot wounds from clinical or radiographic studies<br />Careful history and complete physical exam with appropriate studies will avoid missed injuries<br />Arteriography for zone I and zone III injuries<br />Vascular injuries most immediately life-threatening & missed esophageal injury causes late mortality<br />40<br />dr.ahmad aldhafeeri<br />
  42. 42. Thank you <br />41<br />dr.ahmad aldhafeeri<br />

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