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Trauma

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					Trauma
 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 :
                           pharynx
                           hypopharynx
                           esophagus
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
Evaluation
Airway assessment


   Early airway intervention in the emergency room is
    paramount , especially in the face of an expanding
    hematoma
   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
    intubation
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 .
Circulation

   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
                  intervention
Vascular Injury

    Can be present in 25 % penetrating trauma
   Inspection , palpation & auscultation of the
    H&N , upper extremity and thorax is
    important
   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
    interruption
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
    injury
MANAGEMENT
Zone I

   Symptomatic :
    Arteriography with or without esophageal study



   Asymptomatic :
    Arteriography with or without esophageal study
ZONE II

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



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

   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
    evaluation
   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
    repair
   Large damage → ligation or saphenous vein
    interposition
   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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posted:5/26/2013
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