This document describes two cases of vascular neck trauma. Case 1 involves a motorcycle accident with a metallic foreign body in the neck, causing a parapharyngeal hematoma and tracheal deviation. Imaging revealed a pseudoaneurysm, which was coiled. Case 2 involves a stabbing injury to the neck. Imaging showed an intact vessel and the wound was explored in the operating room. The document then reviews anatomy, mechanisms, signs, investigations and management of vascular neck injuries.

1. Vascular Neck Trauma

2. Case 1

3. Presentation to Lithgow19M, riding motorcycle in the bush- helmet, no leathersFelt sudden sharp severe pain in R anterolateral neckBrought by friends to Lithgow HospitalEntry wound over anterolateral R SCM near angle of mandible, neck swellingCT neck Lightgow -metallic FB 9mm R neck, parapharyngeal haematoma with tracheal deviationTherefore arranged for urgent transfer to Trauma Centre- Westmead Hospital

4. Westmead Hospital- Primary SurveyAirway:Speaking in sentences, hoarse voice. No stridor/resp distress.Trachea and uvula deviated to left.No subcut emphysema or crepitusNo drooling/odynophagia/dysphagiaZone 3 R sided puncture wound over SCMB: SaO2 100% RA, equal air entry, normal RR, no respiratory distress

5. Primary Survey (cont.)C: HR 97, BP 180/70; non-expanding non-pulsatile R neck swelling in SCM, no bruit heardD: GCS 15/15, vocal hoarseness and deviated uvula, moving all limbs spontaneously, no focal neurological deficits, no other cranial nerve abnormalities

6. Secondary SurveyHead, neck, face: findings as above; no other injuries seen; no cervical spine tendernessChest: No chest tenderness, equal AE, vesicular breath soundsAbdomen: soft, non-tenderPelvis: stable and non-tenderUpper & lower limbs: NAD

7. EvaluationZone 3 penetrating neck trauma (above angle of mandible)Potential airway compromise due to extrinsic haematomaModerate-high risk for vascular neck injury due to location of entry wound and haematomaNo sign of acute life threatening vascular compromise (exsanguination/haemorrhage/stroke)

8. ManagementUrgent assessment of airwayNo stridor or respiratory distressNasendoscopy performed by ENT:Oropharyngeal haematoma with mild swellingNormal vocal cords & movementNormal cranial nervesNo need for immediate intubation, if any deterioration for anaesthetic r/v and gaseous intubationDeemed stable for transfer to CT angiography with medical escort

9. Management (cont)IV dexamethasone to minimise airway oedemaO2 therapy via Hudson mask2x large bore cannulae; 1L of Hartmann’s administered intravenously; analgesiaADT and cephazolin administered

10. Imaging

11. Imaging report2x metallic foreign bodies- one at level of C2, one embedded in SCM6mm ECA pseudoaneurysm 2.5cm above angle of mandible

12. Further managementAdmission to ICU for airway, circulatory and neuro observationsVascular consultationAspirinSemi-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

13. Case 2

14. Presentation to WMH- Major Trauma Call58M awoken by partner stabbing his R neck with kitchen knifeWalk in to EDMajor trauma call on arrival

15. Primary SurveyAirway:Speaking in sentencesNo stridor; no tracheal deviation2cm laceration upper zone 2 over R SCM with small non-pulsatile non-expanding haematomaNo active bleedingNo crepitation/emphysemaNo dysphagia/odynophagia/droolingBreathing:SaO2 95%, equal air entry, vesicular breath sounds, no respiratory distress

16. Primary Survey (cont)C: HR 80, BP 140/85, small haematoma at area of stab woundD:GCS 15/15, moving all limbs spontaneously, no focal neurological deficits, no cranial nerve abnormalities

17. Secondary SurveyHead, neck, face: findings as above; no other injuries seen; no cervical spine tendernessChest: No chest tenderness, equal AE, vesicular breath soundsAbdomen: soft, non-tenderPelvis: stable and non-tenderUpper & lower limbs: NAD

18. EvaluationZone 2 penetrating neck trauma (between cricoid cartilage and angle of mandible)Stable from airway/breathing/circulatory perspectivePotential injury to anterior neck vasculatureDeemed safe for transfer for CT angiogram of head and neck

19. Management6L O2 via Hudson Mask2x large bore cannulae, IV Hartmann’s solutionIV cephazolin, ADTNBMCT angiogram of head & neck performed

20. Imaging

21. Imaging report26mm x 20mm x 15mm subcutaneous haematoma anterolateral to R SCM superficial to inferior aspect of parotid glandSmall locule of gas in R SCMVessels intact

22. Further ManagementHDU admission for airway, circulation observationsFor exploration of neck wound with ASU and vascular team early the next day

23. Operative FindingsExpanding R anterior neck haematoma- evacuatedStab wound tract explored- penetration through platysma to lacerated sternocleidomastoid bellyDissection to R IJV- intactR ICA, vagus nerve, identified- intact

24. Further ProgressReturned to HDU postoperatively for airway & circulatory monitoringNo immediate postoperative complicationsDischarged the next day on oral antibiotics

25. 25% of head/neck trauma5-10% all arterial injuryCarotid injury- 10-30% mortality; 15-60% permanent neurologic deficitVascular Neck Injuries

26. Relevant AnatomyICA, ECAJugular vvLat pharynxCr VII, IX, X, XI, XIICCAICA, ECAJugular vvLarynxHypopharynxCr X, XI, XIISubclaa & vvJugular vvCCATracheaOesophagus, thyroid

27. Relevant Anatomy (cont.)

28. Relevant Anatomy (cont.)

29. Vascular traumatic injuriesComplete or partial transectionIntimal flap/dissectionAneurysmPseudoaneurysmFistulaExtrinsic compressionThromboembolism as a result of intimal injury

30. SequelaeHaemorrhageAirway compression, exsanguination, concealed haematomaDistal ischaemiaEither due to vessel injury or thromboembolismStrokes- ACA/MCA (carotid injury), PCA/posterior (vertebral injury)Damage to nearby structures

31. Penetrating neck injury (>90%)Injuries through platysma indicate propensity for injury to deep structuresGunshot wounds and projectilesLow velocity- unpredictable trajectoryHigh velocityCavitation and blunt type injury from concussive forcesStab/knifeStraight and more obvious pathLess tissue damage

32. Blunt Neck Trauma (<10%)Seatbelt injuryHanging/ligature/strangulationPunching/kickingHyperextension/hyperrotation/contusionMechanism is translocational & shear forcesSpectrum from intimal injury (more common) to transection (less common)

33. Associated with dislocation/fractureMandibular, temporal bone fractures can be a/w carotid/jugular injuryVertebral aa injury in general rare- usually a/w C-spine pathology#C-spine (inc Lateral mass #)Ligamentous injuryRotation/hyperextensionNear-hangingExtreme chiropractic manoevres

34. Iatrogenic injuryCVC insertionCerebral AngiographyC-spine surgery, transsphenoidal, skull base surgeryRadiotherapy (stenosis)Nerve blocks (vertebral aa injury)

35. Comorbid injuriesAirway – pharynx, larynx, tracheaPneumothorax, haemothorax (Zone 1)Nerve injuriesCranial VII, IX, X, XI, XIIBrachial plexusCervical sympathetic chain (Horner’s)C-spine, mandibular, temporal fracturesOesophagusParotid, salivary glands, lymph nodesThyroid (Zone 1)

36. Emergent Resuscitation

37. AirwayHigh comorbidity with airway injury & compromiseAssess for:Airway patency- stridor, resp distress, hoarsenessExpanding haematomaEmphysema/crepitus/drooling/dysphagiaENT r/v if possible (+/- nasendoscopy)May require trache(/cricothyroidotomy/intubation), exploration or stentingIf unstable will require emergent OT +/- trache

38. BreathingGeneral principles applyGive Supplemental O2Optimise tissue O2 deliveryAssess chest expansion & for subcut emphysemaNeed CXRMay have comorbid chest injury in high risk mech (eg MVA)Zone 1- risk of assochaemo/pneumothoraxIndex of suspicion for aspiration

39. CirculationGeneral principles of resuscitation applyLarge bore IV accessFluid resuscitation, Xmatch, possible transfusionDirect compression of severe external bleeding- finger/foley catheter in woundIf unstable – immediate OT

40. Circulation (cont)Assess for “Hard” signs of vascular injuryPulsatile bleeding or haematomaExpanding haematomaShock + ongoing bleedingAbsent pulsesNeurovascular symptoms- stroke/TIA symptomsThrills, bruits

41. Circulation (cont)“Soft” signs – warrant further investigationSevere bleeding from neck/pharynxDiminished pulses- superficial temp arterySmall haematomaFractures of skull base, temporal bone, fracture d/location C-spineInjury in anatomical areaIpsilateral Horner’sCranial IX-XII dysfunctionWidened mediastinum

42. DisabilityIf suspicion of C-spine injury- hard collarFocal neurology in stroke territoryshould alert to possible vasc injuryCranial nerve VII --> XII (except VIII)Horner’s syndrome (compression of cervical chain)Brachial plexus injury

43. Other Injuries on Secondary SurveyAerodigestive – oesophagus & pharynxDroolingOdynophagia, dysphagia

44. SummaryAirway injury/compromise common and may r/q emergent managementIf unstable from airway/circulatory point of view needs immediate operative management including explorationExpanding haematoma may cause airway compromiseStroke symptoms, bruits, thrills are a hard sign of vascular injuryIf stable can go on to have further imaging

45. Investigation

46. BloodsHb, haematocrit (blood gas or formal)BSL- must optimise O2 & glucose deliveryABG in airway/breathing compromise

47. Plain radiographyCXR & neck XRForeign bodiesInjury to lung apices- haemo/pneumothoraxMediastinal wideningSurgical emphysema, aerodigestive injuries(C-spine fractures)

48. ScanningDuplex USS useful for Zone 2 injuries- unhelpful for Z1 or 3CT brain & CTA neckCT angiogram may show aneurysm, dissection, fistulae etc (esp with blunt trauma) or occult injuryLocalisation of FBCT brain valuable predictor of outome- infarct on CTB has high mortality, poor neurologic prognosis

49. Endovascular, operative, supportiveManagement

50. Supportive/preop careNurse in HDU environmentSupplemental O2Fluid resuscitationCorrect hypoglycaemiaAnticoagulation for intimal injuries- high risk of thromboembolism; IV heparin followed by 3/12 warfarin

51. Operative managementMandatory exploration of penetrating neck wounds beyond platysma used to be gold standard- 1800’s till 1980’sFogelman & Stewart (1956)- 6% mortality with mandatory exploration, 35% withoutIn 1980’s- increasing operations with negative findingsMore selective approach adopted now

52. Indications for urgent surgeryAirway compromiseHaemodynamic instabilityActive pulsatile haemorrhageExpanding haematoma

53. Indications for surgery (other)Arterial injury requiring primary repairHigh index of suspicion of injuryGunshot wounds, penetration through midlineOngoing bleedingNeed for exploration of other structures

54. Indications for angiography +/- endovascular interventionAssessment of zone 1 & zone 3 injuries unable to be visualised otherwiseEmbolisation of persistent ECA bleedingEmbolisation of osseusverterbal canal vert aa injuryCovered stentgrafts- penetrating wounds/AVF’s/pseudoaneuryms in surgically inaccessible areas, patients who are unfit for surgery, injury to brachiocephalic trunk, proximal CCA/SCA

55. ProcedureSupine position, bolster between scapulae, neck extended, head rotated; access from base of skull to xiphisternumZone 1- oblique supraclavicular incision; may require median sternotomy; thoracic surgical referralZone 2- standard carotid incision- anterior border of SCMZone 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 recommendedIf trachea/oesophagus injured, repair should be protected by SCM