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