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Trauma Powered By Docstoc
 The incidence of blunt trauma to the
neck is reduced in US due to seat belt
The anterior neck is shielded by the
anterior mandible and the clavicle .
When blunt trauma to the does occur ,
 the laryngotracheal tree is the most
         vulnerable to injury
Major vessels injury due to blunt
  trauma is an extermaly rare
        phenomenon .
  It must be considered if the patient
has expanding hematoma carotid bruit
        , or neurologic finding .
Emphysema , dysphagia , odynophagia

Perforation or tear of :
Penetrating trauma
   Stab wound , Gun injury
   M/F : 5/1
   Most injuries occur in the anterior neck
   Type of injury depend on the type of object
    and the area of the neck that is injured .
Anatomic classification
  The platysma , which extends from the
facial muscles to the calvicle , remains the
key anatomic land mark when dealing with
         penetrating neck trauma
Neck Zones
Zone I

   Is the area of the neck between the clavicle
    and the cricoid cartilage
   It contains : proximal common carotid ,
    vertebral artery , subclavian artery , upper
    mediastinal vasculature , lung apices ,
    trachea , esophagus , thoracic duct
It is difficult to gain emergent proximal
     control of hemorrhage and it is
     difficult to expose intrathoracic
          neurovascular structure
Zone II

   Extending between cricoid cartilage and the
    angle of the mandible

   Containing carotid bifurcation , vertebral
    artery , IJV , larynx , trachea , esophagus ,
    vagus , RLN , spinal cord
Zone III

   Is from the angle of the mandible to the base
    of the skull

    contains distal ECA branches , vertebral
    artery , salivary glands , pharynx , spinal cord
    , CN VII , VIII , IX , X , XII
It is difficult to gain emergent distal
    control of hemorrhage and it is
     difficult to expose skull base
      neurovascular structures
Airway assessment

   Early airway intervention in the emergency room is
    paramount , especially in the face of an expanding
   A quick survey of the patientُ s airway status must
    be made .
   A cricothyrotomy or vertical tracheotomy is the
    preferred of choice compared to oral or nasal
Endotracheal intubation may be considered
   in select situation , but it may further
     exacerbate bleeding , pharyngeal
  perforation , or laryngotracheal injury
One must assume a cervical spine injury
until further testing can be done . This is
 especially important whenever one is
     establishing a surgical airway .

   Any frank bleeding must be controlled with
    direct pressure only .
   Any use of clamping instrument should be
    condemned .
   Establishment large –bore IV access
Immediate surgical management

   Life-threatening hemorrhage
   Hemodynamic instability
   Expanding hematoma
The operating room is the only place
where a wound is explored or probed
  or a foreign body is removed .
    Secondary survey and definitive
management can be dine in a system – by
system fashion once the airway has been
      addressed and the patient is
      hemodaynamically stable .
Respiratory tract injury

   10% penetrating trauma
   Oropharynx …….lung apices
   Cyanosis
   Air per wound
   Subcutaneous emphysema
   Hemoptysis
   Dysphonia
   Hoarseness
   Decreased breath sound
An initial respiratory tract injury may appear
  stable but may rapidly decompensate ,
     requiring emergent surgical airway
Vascular Injury

    Can be present in 25 % penetrating trauma
   Inspection , palpation & auscultation of the
    H&N , upper extremity and thorax is
   Hypovolumic shock , frank brisk bleeding ,
    expanding hematoma , decreased breath
    sound , decreased radial pulse , carotid bruit
Digestive tract injury

   In 5% penetrating trauma
   Most frequent missed injury
   Dysphagia , odynophagia , hematemesis ,
    crepitus , free air on imaging
   Early intervention to exteriorize the leak to
    prevent mediastinitis
Nervous system

   Complete or incomplete spinal cord
    transection should be considered : localizing
    & lateralizing deficit
   CN , brachial plexus , phrenic nerve
   Hemiplagia due to carotid or vertebral
Soft tissue injury

   Glandular or duct injury :
    Saliva existing in the wound , associated
    facial or hypoglossal injury

   Left sided trauma in zone III : thoracic duct
Zone I

   Symptomatic :
    Arteriography with or without esophageal study

   Asymptomatic :
    Arteriography with or without esophageal study

   Symptomatic :
             To operating room if hemoptysis ,
    dysphsgia , or nerve deficit is present

   Asymptomatic :
  Surgical exploration of zone II still
remains an area of great controversy

   Symptomatic :
     Arteriography with or without mbolization

   Asymptomatic :
    With or without arteriography for possible occult
    vascular injury ( all patients admitted for overnight
    observation )
Diagnostic imaging

They will give important information and allow
  the surgeon to manage the patient in a more
  selective fashion
   Arteriography in zone I , III
   Esophagography ( 90% sensitivity )
   CT ( laryngotracheal complex )
   Flexible laryngoscopy in awake patient and
    stable patient
All attempts should be made to clear
    the cervical spine prior to any
        operative manipulation
   Awake tracheostomy → Rigid endoscopic
   Parenteral antibiotic
   Tetanus toxoid booster
Occult vascular injury in zone III may often be
 managed with endovascular embolization but
 on rare occasion a lateral swing
 mandibulotomy may be required for surgical
 repair .
   Zone II vascular injuries can be
directly accessed via a transcervical
             approach .
Vascular injury

   Simple laceration of IJV & carotid → primary
   Large damage → ligation or saphenous vein
   Zone I injury : sternotomy ot thoracotomy
All arterial vessels should be repaired
 , and venous injuries can be ligated
Pharyngoesophageal injuries

   Explored , debrided and closed primerily in
    one or two layer
   Drained with either a closed suction or a
    Penrose drain
   Direct insertion a NGT
   Late diagnosis (12h) drained wound
Laryngotracheal injury

   Unstable patient : tracheostomy
   Stable patient : flexible laryngoscopy ± CT
   Inspection of carotid sheath , esophagus &
    cartilaginous frame work
   Repair of endolarynx : laryngofissure Thyroid
    cartilage fracture : reapproximate & suturing
   Tracheal laceration can be sutured or used for the
    tracheostomy site

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