Neck Trauma

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Neck Trauma

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Neck Trauma

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

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