Vascular neck trauma
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Vascular neck trauma Vascular neck trauma Presentation Transcript

  • Vascular Neck Trauma
  • Case 1
  • Presentation to Lithgow
    19M, riding motorcycle in the bush- helmet, no leathers
    Felt sudden sharp severe pain in R anterolateral neck
    Brought by friends to Lithgow Hospital
    Entry wound over anterolateral R SCM near angle of mandible, neck swelling
    CT neck Lightgow -metallic FB 9mm R neck, parapharyngeal haematoma with tracheal deviation
    Therefore arranged for urgent transfer to Trauma Centre- Westmead Hospital
  • Westmead Hospital- Primary Survey
    Airway:
    Speaking in sentences, hoarse voice. No stridor/resp distress.
    Trachea and uvula deviated to left.
    No subcut emphysema or crepitus
    No drooling/odynophagia/dysphagia
    Zone 3 R sided puncture wound over SCM
    B: SaO2 100% RA, equal air entry, normal RR, no respiratory distress
  • Primary Survey (cont.)
    C: HR 97, BP 180/70; non-expanding non-pulsatile R neck swelling in SCM, no bruit heard
    D: GCS 15/15, vocal hoarseness and deviated uvula, moving all limbs spontaneously, no focal neurological deficits, no other cranial nerve abnormalities
  • Secondary Survey
    Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness
    Chest: No chest tenderness, equal AE, vesicular breath sounds
    Abdomen: soft, non-tender
    Pelvis: stable and non-tender
    Upper & lower limbs: NAD
  • Evaluation
    Zone 3 penetrating neck trauma (above angle of mandible)
    Potential airway compromise due to extrinsic haematoma
    Moderate-high risk for vascular neck injury due to location of entry wound and haematoma
    No sign of acute life threatening vascular compromise (exsanguination/haemorrhage/stroke)
  • Management
    Urgent assessment of airway
    No stridor or respiratory distress
    Nasendoscopy performed by ENT:
    Oropharyngeal haematoma with mild swelling
    Normal vocal cords & movement
    Normal cranial nerves
    No need for immediate intubation, if any deterioration for anaesthetic r/v and gaseous intubation
    Deemed stable for transfer to CT angiography with medical escort
  • Management (cont)
    IV dexamethasone to minimise airway oedema
    O2 therapy via Hudson mask
    2x large bore cannulae; 1L of Hartmann’s administered intravenously; analgesia
    ADT and cephazolin administered
  • Imaging
  • Imaging report
    2x metallic foreign bodies- one at level of C2, one embedded in SCM
    6mm ECA pseudoaneurysm 2.5cm above angle of mandible
  • Further management
    Admission to ICU for airway, circulatory and neuro observations
    Vascular consultation
    Aspirin
    Semi-electively 3-4 days post injury R Cerebral & carotid angiogram for management of pseudoaneurysm with coiling performed.
    No immediate complications; d/c home on oral antibiotics
  • Case 2
  • Presentation to WMH- Major Trauma Call
    58M awoken by partner stabbing his R neck with kitchen knife
    Walk in to ED
    Major trauma call on arrival
  • Primary Survey
    Airway:
    Speaking in sentences
    No stridor; no tracheal deviation
    2cm laceration upper zone 2 over R SCM with small non-pulsatile non-expanding haematoma
    No active bleeding
    No crepitation/emphysema
    No dysphagia/odynophagia/drooling
    Breathing:
    SaO2 95%, equal air entry, vesicular breath sounds, no respiratory distress
  • Primary Survey (cont)
    C: HR 80, BP 140/85, small haematoma at area of stab wound
    D:GCS 15/15, moving all limbs spontaneously, no focal neurological deficits, no cranial nerve abnormalities
  • Secondary Survey
    Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness
    Chest: No chest tenderness, equal AE, vesicular breath sounds
    Abdomen: soft, non-tender
    Pelvis: stable and non-tender
    Upper & lower limbs: NAD
  • Evaluation
    Zone 2 penetrating neck trauma (between cricoid cartilage and angle of mandible)
    Stable from airway/breathing/circulatory perspective
    Potential injury to anterior neck vasculature
    Deemed safe for transfer for CT angiogram of head and neck
  • Management
    6L O2 via Hudson Mask
    2x large bore cannulae, IV Hartmann’s solution
    IV cephazolin, ADT
    NBM
    CT angiogram of head & neck performed
  • Imaging
  • Imaging report
    26mm x 20mm x 15mm subcutaneous haematoma anterolateral to R SCM superficial to inferior aspect of parotid gland
    Small locule of gas in R SCM
    Vessels intact
  • Further Management
    HDU admission for airway, circulation observations
    For exploration of neck wound with ASU and vascular team early the next day
  • Operative Findings
    Expanding R anterior neck haematoma- evacuated
    Stab wound tract explored- penetration through platysma to lacerated sternocleidomastoid belly
    Dissection to R IJV- intact
    R ICA, vagus nerve, identified- intact
  • Further Progress
    Returned to HDU postoperatively for airway & circulatory monitoring
    No immediate postoperative complications
    Discharged the next day on oral antibiotics
  • 25% of head/neck trauma
    5-10% all arterial injury
    Carotid injury- 10-30% mortality; 15-60% permanent neurologic deficit
    Vascular Neck Injuries
  • Relevant Anatomy
    ICA, ECA
    Jugular vv
    Lat pharynx
    Cr VII, IX, X, XI, XII
    CCA
    ICA, ECA
    Jugular vv
    Larynx
    Hypopharynx
    Cr X, XI, XII
    Subclaa & vv
    Jugular vv
    CCA
    Trachea
    Oesophagus, thyroid
  • Relevant Anatomy (cont.)
  • Relevant Anatomy (cont.)
  • Vascular traumatic injuries
    Complete or partial transection
    Intimal flap/dissection
    Aneurysm
    Pseudoaneurysm
    Fistula
    Extrinsic compression
    Thromboembolism as a result of intimal injury
  • Sequelae
    Haemorrhage
    Airway compression, exsanguination, concealed haematoma
    Distal ischaemia
    Either due to vessel injury or thromboembolism
    Strokes- ACA/MCA (carotid injury), PCA/posterior (vertebral injury)
    Damage to nearby structures
  • Penetrating neck injury (>90%)
    Injuries through platysma indicate propensity for injury to deep structures
    Gunshot wounds and projectiles
    Low velocity- unpredictable trajectory
    High velocity
    Cavitation and blunt type injury from concussive forces
    Stab/knife
    Straight and more obvious path
    Less tissue damage
  • Blunt Neck Trauma (<10%)
    Seatbelt injury
    Hanging/ligature/strangulation
    Punching/kicking
    Hyperextension/hyperrotation/contusion
    Mechanism is translocational & shear forces
    Spectrum from intimal injury (more common) to transection (less common)
  • Associated with dislocation/fracture
    Mandibular, temporal bone fractures can be a/w carotid/jugular injury
    Vertebral aa injury in general rare- usually a/w C-spine pathology
    #C-spine (inc Lateral mass #)
    Ligamentous injury
    Rotation/hyperextension
    Near-hanging
    Extreme chiropractic manoevres
  • Iatrogenic injury
    CVC insertion
    Cerebral Angiography
    C-spine surgery, transsphenoidal, skull base surgery
    Radiotherapy (stenosis)
    Nerve blocks (vertebral aa injury)
  • Comorbid injuries
    Airway – pharynx, larynx, trachea
    Pneumothorax, haemothorax (Zone 1)
    Nerve injuries
    Cranial VII, IX, X, XI, XII
    Brachial plexus
    Cervical sympathetic chain (Horner’s)
    C-spine, mandibular, temporal fractures
    Oesophagus
    Parotid, salivary glands, lymph nodes
    Thyroid (Zone 1)
  • Emergent Resuscitation
  • Airway
    High comorbidity with airway injury & compromise
    Assess for:
    Airway patency- stridor, resp distress, hoarseness
    Expanding haematoma
    Emphysema/crepitus/drooling/dysphagia
    ENT r/v if possible (+/- nasendoscopy)
    May require trache(/cricothyroidotomy/intubation), exploration or stenting
    If unstable will require emergent OT +/- trache
  • Breathing
    General principles apply
    Give Supplemental O2
    Optimise tissue O2 delivery
    Assess chest expansion & for subcut emphysema
    Need CXR
    May have comorbid chest injury in high risk mech (eg MVA)
    Zone 1- risk of assochaemo/pneumothorax
    Index of suspicion for aspiration
  • Circulation
    General principles of resuscitation apply
    Large bore IV access
    Fluid resuscitation, Xmatch, possible transfusion
    Direct compression of severe external bleeding- finger/foley catheter in wound
    If unstable – immediate OT
  • Circulation (cont)
    Assess for “Hard” signs of vascular injury
    Pulsatile bleeding or haematoma
    Expanding haematoma
    Shock + ongoing bleeding
    Absent pulses
    Neurovascular symptoms- stroke/TIA symptoms
    Thrills, bruits
  • Circulation (cont)
    “Soft” signs – warrant further investigation
    Severe bleeding from neck/pharynx
    Diminished pulses- superficial temp artery
    Small haematoma
    Fractures of skull base, temporal bone, fracture d/location C-spine
    Injury in anatomical area
    Ipsilateral Horner’s
    Cranial IX-XII dysfunction
    Widened mediastinum
  • Disability
    If suspicion of C-spine injury- hard collar
    Focal neurology in stroke territoryshould alert to possible vasc injury
    Cranial nerve VII --> XII (except VIII)
    Horner’s syndrome (compression of cervical chain)
    Brachial plexus injury
  • Other Injuries on Secondary Survey
    Aerodigestive – oesophagus & pharynx
    Drooling
    Odynophagia, dysphagia
  • Summary
    Airway injury/compromise common and may r/q emergent management
    If unstable from airway/circulatory point of view needs immediate operative management including exploration
    Expanding haematoma may cause airway compromise
    Stroke symptoms, bruits, thrills are a hard sign of vascular injury
    If stable can go on to have further imaging
  • Investigation
  • Bloods
    Hb, haematocrit (blood gas or formal)
    BSL- must optimise O2 & glucose delivery
    ABG in airway/breathing compromise
  • Plain radiography
    CXR & neck XR
    Foreign bodies
    Injury to lung apices- haemo/pneumothorax
    Mediastinal widening
    Surgical emphysema, aerodigestive injuries
    (C-spine fractures)
  • Scanning
    Duplex USS useful for Zone 2 injuries- unhelpful for Z1 or 3
    CT brain & CTA neck
    CT angiogram may show aneurysm, dissection, fistulae etc (esp with blunt trauma) or occult injury
    Localisation of FB
    CT brain valuable predictor of outome- infarct on CTB has high mortality, poor neurologic prognosis
  • Endovascular, operative, supportive
    Management
  • Supportive/preop care
    Nurse in HDU environment
    Supplemental O2
    Fluid resuscitation
    Correct hypoglycaemia
    Anticoagulation for intimal injuries- high risk of thromboembolism; IV heparin followed by 3/12 warfarin
  • Operative management
    Mandatory exploration of penetrating neck wounds beyond platysma used to be gold standard- 1800’s till 1980’s
    Fogelman & Stewart (1956)- 6% mortality with mandatory exploration, 35% without
    In 1980’s- increasing operations with negative findings
    More selective approach adopted now
  • Indications for urgent surgery
    Airway compromise
    Haemodynamic instability
    Active pulsatile haemorrhage
    Expanding haematoma
  • Indications for surgery (other)
    Arterial injury requiring primary repair
    High index of suspicion of injury
    Gunshot wounds, penetration through midline
    Ongoing bleeding
    Need for exploration of other structures
  • Indications for angiography +/- endovascular intervention
    Assessment of zone 1 & zone 3 injuries unable to be visualised otherwise
    Embolisation of persistent ECA bleeding
    Embolisation of osseusverterbal canal vert aa injury
    Covered stentgrafts- penetrating wounds/AVF’s/pseudoaneuryms in surgically inaccessible areas, patients who are unfit for surgery, injury to brachiocephalic trunk, proximal CCA/SCA
  • Procedure
    Supine position, bolster between scapulae, neck extended, head rotated; access from base of skull to xiphisternum
    Zone 1- oblique supraclavicular incision; may require median sternotomy; thoracic surgical referral
    Zone 2- standard carotid incision- anterior border of SCM
    Zone 3- similar to Z2 but may r/q mandibulotomy or subluxation; 2cm below mid mandible, 1cm facial notch (avoid marginal br facial nn)
    Arteries should be repaired (primarily if possible; bypass if simple repair not possible)
    ECA may be ligated if necessary (if ICA ok)
    Venous injuries (inc IJ) may be ligated. Complex venous repair not recommended
    If trachea/oesophagus injured, repair should be protected by SCM