Vascular neck trauma


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Vascular neck trauma

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