2. Complex network of neurovasuclar & muscular
structures supported by various fascial planes.
In the neck multiple vital structures are vulnerable to
injury in a small anatomic area and not protected by
bone.
3. Neck Injuries
Neck trauma mechanisms:
blunt
penetrating : 5-10% of all trauma cases
The types of injuries:
airway (laryngotracheal),
digestive tract (pharyngoesophageal),
vascular system
neurologic system
5. Three basic types: low velocity
(handguns), high velocity
(rifles) and shotguns.
Handguns ~ 400ft/lb,
Rifles 3000ft/lb,
Shotgun energy and impact
varies with distance
6. Projectile injury mechanics
Kinetic Injury of Missile: more energy = more damage
•Velocity: higher velocity = more KE,
•Yaw –“tumbling”, deflection of the bullet around the
axis of the travel.
•More tumble = more transmitted energy, larger
damage path
•Strong metal jacket allows through and through
injury
7. HANDGUNS-
Classified by projectile type, speed and calibre.
Tumbling bullet : deflection of the bullet around the
axis of the travel, causes more injury in a wider path
Low velocity bullets(lead shielded) leave a radiographic
pathway
8. RIFLE
Hunting rifle- soft tip bullets create larger cavity, no exit
wound, fragments causing injury far away from
primary path.
Military rifle- bullets create clean hole, through and
through wound without lead track to follow
High velocity missiles tears tissues & transmits energy
to surrounding tissue.
Cavity upto 30 times size of missile created & pulsate 5-
10ms creating
waves of contraction and expansion of tissues.
Hence the finding of punctured viscus without direct
penetration- alerts the surgeon to examine trachea and
esophagus even when bullet is 2 inches away.
9.
10. Bullet Tip
•“Expanding bullet” –hollowpoint, softnose
•More energy transmission and more soft tissue injury
•Entry/Exit wound, pathway through tissue
13. Roon & Christensen`s Classification
Zone 1: superiorly from the sternal notch & clavicles
to the cricoid cartilage (injury affects both neck &
mediastinal structures)
Zone 2: cricoid cartilage to the angle of the
mandible
Zone 3: angle of the mandible to the
14. ZONES OF NECK - CONTENTS
Zone I: includes the
vertebral and proximal
carotid arteries, major
thoracic vessels, superior
mediastinum, lungs,
esophagus, trachea,
thoracic duct, spinal cord
15. Zone II: involve the carotid and vertebral arteries,
jugular veins, esophagus, trachea, larynx, and spinal
cord
Zone III: includes the distal carotid and vertebral
arteries, pharynx, and spinal cord
16. ZONE I considerations
Dangerous Area, Mortality –12%
•Close proximity of vasculature to thorax
•Osseous Shield : bony thorax and clavicle
•Protects against injury
•Surgical Access difficult
•Surgical Access
•May require sternotomy or thoracotomy
•Mandatory exploration is NOT recommended
17. ZONE II considerations
Largest and most commonly involved area ~60-75%
•No Osseous Shield
•Surgical Access “Easy”
•Proximal and Distal control of vasculature “easy”
•Fascial layers may tamponade
•Elective vs Mandatory Exploration
18. ZONE III considerations
Dangerous Area
•Proximity of vasculature to skull base, high carotid
injury
Cranial nerve injury at skull base
•Surgical Access difficult
•Surgical Access
•Mandibulotomy
•Craniotomy
•Mandatory exploration is NOT recommended
•Cranial neuropathies may be indicative of injury to
nearby vasculature
•Frequent examination oral cavity
19. FASCIAL PLANES
Platysma: thin muscle covers the entire anterior triangle
and the anteroinferior aspect of the posterior triangle;
serves as an important planar landmark when evaluating
penetrating neck injuries
Deep cervical fascia: invest deep structures; important due
to the pretracheal deep fascia’s communication to the
anterior mediastinum (neck trauma can lead to
mediastinitis)
23. ESOPHAGEAL INJURIES
•Subcutaneous Emphysema
•Dysphagia
•Odynophagia
•Hematemesis
•Hemoptysis
•Tachycardia
•Fever
•Most commonly missed zone II injury
•SignificantDelayedmorbidity and mortality
24. Hard Signs
Ongoing hemorrhage
Large or expanding hematoma
Bruit
Massive blood loss at scene
Hemiparesis or hemiplegia
Extensive subcutaneous emphysema
Stridor
25. INITIAL MANAGEMENT
ABC’s
Always be ready for Intubation,
Cricothyroidotomy, Tracheostomy (multible
intubation attempts might enlarge a pyriform
sinus laceration/ tracheal tear may be exacerated
by neck extensions)
Extension of neck should be avoided until a
cervical spine injury is ruled out
Direct pressure for bleeding
26. AP and Lateral neck and chest x-rays( chest tube
insertion in pneumothorax)
Look for vascular injury(pulse deficit,active
bleeding,hypotension, expanding hematoma) in
high volume trauma
Acute spinal injury- hypotension without
tachycardia
Look for Cranial Nerve injury, in cases with 12th
nerve injury suspect carotid artery injury
Horners Syndrome- injury to sympathetic chain or
carotid atery
29. Angiography
In zone I and zone III : routinely
When b/l neck involved, 4 vessel angiography : b/l
carotid and vertebral arteries
Zone II injuries : easily accesible, low risk for
exploration
Angiography : stable pts with persistent hemorrhage /
neurologic deficits
30.
31. MANAGEMENT
Zone 1 dangerous area- vascular strusture close to
neck, osseous shield makes surgical exploration
difficult.
Right side approached through median
sternotomy, left side by left anterior thoracotomy.
High fatality rate.
32. Zone 2 –common 60-75%
Mandatory or selective exploration depending on
signs, symptoms, haemodynamic stability,
diagnostic radiographic , endoscopic techniques,
angiography
Zone 3- protected by skeletal structures and
difficult to explore. May need to displace or divide
mandible.
Injury to cranial nerves exiting skull base indicate
injuries To great vessels in their proximity(may
necessitate craniotomy for exploration)
33.
34. MANDATORY VS SELECTIVE MANAGEMENT
Mandatory immediate surgical exploration
Massive bleeding, expanding hematoma, non
expanding hematoma with haemodynamic
instability, haemomediastinum, hemothorax,
hypovolemic shock
Selective exploration
Hemodynamically stable, non life threatening
injuries, Can undergo imaging investigations.
37. Exploration of Neck
general principles
GA
Airway- nasotracheal/orotracheal intubation;
cricothyroidotomy/traecheotomy
Position- supine, neck extended, turned to opposite
side(if no C spine injury)
Exposure-chest & face for zone 1 & 3 injuries
Approach- localised injury :horizontal skin crease
insicion, subplatysmal flaps;
wider exploration: lond incision along anterior border
of sternocleidomastoid.
Additional exposure:zone 1 divide omohyoid muscle,
for bilateral exploration :apron flap; zone 3 –anterior
dislocation of mandible.
38. Active bleeding should be controlled with digital
pressure until direct vascular control is achieved
Wounds should not be probed, cannulated or locally
explored
these can dislodge clot and lead to uncontrolled
hemorrhage or embolism
39. • Zone I - SCM incision + sternotomy
• Zone II - SCM incision
• Zone III - post-auricular extension with SCM
incision + mandibular subluxation
Operative Approach
40. • Provides exposure of the carotid sheath,
pharynx and cervical esophagus
• Can be lengthened to provide more extensive
proximal or distal exposure
• If bilateral exploration is necessary, separate
incisions can be done
SCM Incision
41. • Neck trauma damages cervical vessels in 25%
of cases
• Penetrating trauma predominates
− 30% have associated injuries in the neck and
thorax
• Blunt trauma accounts for < 10% of injuries
− mortality rate = 10 – 30%
Cervical Vascular Injuries
42. VASCULAR PENETRATION
Zone I : Thoracic surgery
low cervical incision : sufficient exposure
Zone II : Injuries at skull base may require
mandibulotomy for exposure
ICA injury : fogarty catheter through PruitT Inahara
shunt
All veins can be safely ligated, if both ijv ‘s injured : one
side repaired.
43.
44. Common carotid/ ICA in zone II : exploration is
mandatory
If the artery is not pulsating : external carotid branches
may be followed retrograde from facial artery at
submandibular/ superiro thyroid artery
Vascular injuries : end to end anastomosis
autovenous grafting
ligation for irreparable injuries
45. • Injuries to the ICA are more problematic
• Simple injuries with no interruption of flow
should be repaired
• Injuries to CCA or ICA with interrupted flow
in the vessel, repair creates a theoretical
disadvantage
Management
46.
47. • Interruption of flow may lead to focal brain
ischemia and partial disruption of blood-
brain barrier
• Sudden restoration of blood flow may cause
hemorrhage in the area of ischemia and
worsen the extent of brain injury
• Converted an ischemic infarct into a
hemorrhagic infarct
Disadvantage
