Epidemiology
Up to 5% of injuries in urban centers
“Tiger Country” due to anatomy
“Significant” cases c 44% vascular injuries, 19 % aerodigestive injuries
Up to 10% mortality
Significant = Penetration of Platysma - use to operate on all traumas penetrating platysma
Criteria for Mandatory Exploration in the past
Based on WW II/Korean War and by Parkland Data from ’50s1:
- 35% mortality with selective surgery versus 6% mortality with mandatory exploration
- Downside = 25-75% negative exploration rates
Subsequent studies in modern imaging era favors selective approach with low velocity trauma
Anatomy
Complex
Systematic Approach to Penetrating Neck Trauma
1st Priority = Airway Control
2nd Priority = Stop Any Active Bleeding
THEN – evaluate extent of injury
Clinical exam can detect >90% of relevant injuries
Incidence of unstable C-spine injury after penetrating injury <1% (and majority of these already have cord injuries, more common to have significant instability after blunt trauma)
Identify:
- Cause of Injury: GSW (usually more severe), Knife, Other
- Site of Injury: Anterior triangle (anterior to SCM) vs. Posterior triangle (posterior to SCM, usually less severe injuries)
- Level of injury:
Zone 1: clavicles to cricoid
Zone 2: cricoid to mandibular angle (more straight forward to manage)
Zone 3: mandibular angle to base of skull
- Wound Tract: Towards/away from midline, towards/away from clavicle, can't always assess
- Vascular Structures:
1. Active Bleeding: none, minor, moderate, severe
2. Hypovolemia: BP>100, BP 60-90, BP <60
3. Hematoma: None, small, moderate, large, expanding, pulsatile
4. Peripheral Pulses (compare c contralateral side): distal carotid, superficial temporal, brachial or radial (normal, diminished, absent - use doppler)
5. Affected Extremity’s API: >=1, 0.9, <0.9
6. Bruit: no, yes (location)
- Aerodigestive Tract
1. Hemoptysis: ask patient to cough and spit on paper
2. Air bubbling through wound (ask for cough)
3. SQ emphysema
4. Hoarseness
5. Pain on swallowing sputum
6. Hematemesis
- Nervous system: A) GCS and B) Localizing Signs:
1. Pupils: normal, anisocoria
2. Cord: normal, monoparesis, monoplegia, paraparesis, paraplegia, quadraplegia
3. Horner's syndrome: myosis (can't dilate), ptosis (can't open eyes wide), anhydrosis (can't sweat) from loss of sympathetic trunk (can't fight/flight)
4. Cranial nerves: VII (lift eyebrows), VIII (soft palate), X (Hoarseness), XI (Lift Shoulders), XII (Tongue)
5. Brachial plexus: Median (make fist), Radial (extend wrist), Ulnar (spread fingers), Musculocutaneous (flex arm), axillary (abduct shoulder)
Do No Harm
Avoid IVs on side of injury, groin line reasonable
No NG until OR
Don’t probe wounds
Proper positioning
Avoid trachestomy c vascular repairs
OR Indications
Hemodynamic Instability
Expanding Hematoma
Pulsatile Bleeing
Neurologic Deterioration
Air Bubbling in Wound
Miami Neck Injury Algorithm (with angio adjustment)
Penetrating neck injury-->
stable-->obvious superficial injury-->
yes-->observation
no-->High resolution CT Angiogram-->
negative-->observe
Suspicion for aerodigestive injury-->esophagogram or endoscopy-->
negative-->observe
positive-->OR
Vascular injury-->
positive in zone 1 or 3 or inconclusive-->diagnostic/therapeutic angio
Positive in Zone 2 -->OR
unstable or indication for intervention (see above)-->
OR if zone 2
diagnostic/therapeutic angio if zone 1 or 3
CTA
Miami CTA Experience
Prospective, blinded 2 year study c 60 Trauma Neck Angio patients
- Sensitivity: 90%, Specificity: 100%, NPV: 98%, PPV: 100% in regards to vascular injuries
- Single Injury missed due to technical error c proximal CCA not included in lowest cuts
Subsequent prospective study c CTA as primary imaging modality for suspected arterial injuries
- 175 patients c 27 (16%) arterial injuries
- Sensitivity: 100% Specificity: 99%, NPV: 100% PPV: 93% in regards to vascular injuries
- 81 associated injuries visualized: 28 c-spine fxs, 25 facial/mandibular fxs, 4 aerodigestive injuries, 25 soft tissue hematomas causing compression
LAC CTA Experience
106 penetrating neck injuries over 16 months
2% nondxic rate due to streak artifact from fragments
100% sensitivity, 94% specificity for vascular injuries
CTA Limitations
Streak Artifact from retained fragments
No interventional capability
Potential to miss small intimal injuries/PAs
Does not “rule out” aerodigestive injuries - need esophagoscopy and esophagram
But it does eliminate negative neck explorations
Neck Exploration
Incisions - just like thyroid (collar incision) or carotid (SCM incision), can use combo of the two
Zone 2 - Standard Approach just like CEA, facial vein is the gatekeeper
Vascular
Specific Injuries
IJ Vein – Lateral Venorrhaphy or Ligate (Unilateral only)
ICA – Patch or Vein Bypass (Ligate only if no other option)
Distal CCA – Patch, Vein Bypass (need larger vein), or ligation
Proximal CCA – Patch, Synthetic Bypass,or ligation
Critieria for Non-Op Carotid Injury Management
Small intimal defects
Pseudoaneurysms < 5mm
Dense Neuro deficit & CT c large infarct
Occluded ICA c normal Neuro exam - need to be anticoagulated x 3 months to limit extension
ALL OTHERS MUST BE REPAIRED
Bilateral Injuries – Expose c “Trap Door”
Distal Zone 2 Injuries w/ multiple obstacles
- CN XII - avoid it
- Digastric muscle - transect it, avoid spinal accessory nerve
- SCM - transect it
- Mandibular angle - hockey stick around it
- CN XI - beware of it 2 fingerbreadths, crosses under sternocleidomastoid at the angle of the mandible, posterior to the digastric muscle
Zone 3 Injuries
{
Zone 3 case
Combat Frag Injury c Pulsatile Bleeding in STP, Packed, Taken to OR
Ready for Cric/Trach c Induction
Trachea deviated on intubation
Positioned for Neck Exploration
Wound Explored – pulsatile bleeding from Facial Artery Distribution
Controllable c pressure in Inframandibular R Neck
Controlled c packing + Skin “Closure”
Pt stable – Sent Intubated to 332nd
Arrived stable at Balad
CT Angio negative for bleeder, Large “Chip” Fx of Mandibular Angle
No recurrent bleeding on washout
No stabilization needed --> washed out and packed loosely
15 minutes post-op: pulsatile bleeding from wound
Taken back to OR – bleeding Lingual Artery Ligated
Formal Neck Dissection for persistent bleeding:
50% ICA tear 1 cm below base of skull
Ligated to prevent exsanguination
Went on to have small parietal infarct but ultimate functional outcome
}
? How to Best Control Zone 3 Bleeding ?
ICA Ligation
Indicated for:
1) DENSE neuro deficits preop and no prograde flow intraop
2) Last resort to prevent exanguination
CVA rate = ? no one really knows
Need Distal Control of Back Bleeding - w/ fogherty balloon if needed
Future of Zone 3 Injuries - angiographic stenting, angioembolization
Zone 1 Vascular Injuries
Consider Angio options
Expose/Control via Median Sternotomy
Left subclavian only major Neck/Outlet vessel not exposed well via sternotomy - left anterior lateral thoracotomy with digital control w/ a clavicular incision
Initial Control of Left Subclavian Bleeding
Op Management
Proximal Control via Sternotomy
- Make Sternotomy
- Open Pericardium +/- Thymic Division
- Follow SVC up to L Inominate Vein
- +/- Divide L Inominate Vein (must avoid if R IJ injured) "gatekeeper of the mediastinum"
- Locate/Avoid R Vagus Nerve
- ID & Address injuries
Incision of Thymus
Pericardial Opening
Subclavian Vascular Injuries
60% die in field, 30% in ER, 15% after OR
Higher mortality c venous injuries - lack of vasoconstriction, air embolism
1/3 have concurrent brachial plexus injury
Sternotomy extends to SCM or Clavicular Incision
Clavicular Incision
Rarely used: trauma or ax/fem bypasses
Position c Roll under shoulder (like c CVL)
Head turned away
Arm slightly at side
(like Axillary Bypass cases)
Incise over clavicle from SC Joint to midclavicle
Extend as needed toward deltapectoral groove
Incise Pec Major/Reflect Pec Minor as needed for distal control
Can ligate SC Vein but poor outcomes c arterial ligation
Subclavicular Extension
Incise/Elevate Periosteum
Develop posterior plane
Transect c Gigli Saw (Slightly lateral to mid clavicle)
Elevate clavicle/free from subclavius muscle/ligaments
Incise SC Joint Ligaments (including clavicular head of SCM)
Free clavicle
Ligate EJ
Medially Retract Sternal Head of SCM Muscle
Superiorally retract clavicular SCM
Address venous bleeding
Beware of Phrenic Nerve posterioral to SCM on the surface of the anterior scalene
Retract SCV inferiorally
Retract or Transect Omohyoid
Dissect through fibrofatty tissue
Laterally retract phrenic nerve on the surface of the anterior scalene
Incise Anterior Scalene
Can then approach SCA, TC trunk, and proximal vertebral artery
Beware of Thoracic duct on the Left emptying at junction of IJV, brachiocephalic and subclavian
Ligate if injured
? Prophylactic Fibrin Glue ?
Verterbral Artery
1-3% of Neck Injuries
Very difficult to manage
Treatment of choice: Angioembolization (even just pack and send to angio if necessary)
Control/ligate proximally
Distal control c Fogarty if possible
Vertebral Artery – Distal Exposure
Retract SCM as usual
Retract IJ & Carotid Sheath Medially
Connect c lower incision as open deep cervical fascia
Sweep Longus Coli Away
Control c Bone Wax, Clip, Hemostatics, or Ligation
{
Aerodigestive Case 1
1245 – Army PFC sustains ricochet GSW to Neck
1318 – arrives SSTP
P 85 RR 20 BP 142/74 02Sat 99%
GCS 15
Secondary Survey
Midline penetration below cricoid
+ Hoarsenenss
+/- Air from Wound
UEs NV Intact
No hematoma
PreOp Course
Abx Given
CXR – No PTX, Frag in mid Neck
Operative Course
Explored through Collar Incision
Ready for Trach at induction.
Anterior Tracheal Lac at 4th Ring noted
No post wound visible from ant. Inspection
Frag not found
ET tube advanced to clear balloon from field
Additional XRs - Frag lying posterior, slightly inferior to level of anterior lac
Trachea medialized
Inf. Thyroid Artery Taken
RLN Visualized
Esophagus Isolated
Esophageal Exposure – Other Options
- Intraop EGD
- Air Insufflation through NE tube
-Contralateral Incision
- “Back Door” Exposure
Fragments found in Esophageal Wall
Frag removed and Esophagus inspected
Longitudinal Myotomy performed above and below site – Mucosa intact
NG carefully placed to just above injury and air insufflation under irrigation fluid resulted in no air extravasation.
Esophageal Muscularis closed tranversely
Posterior-lateral trachea visualized, injury found and closed
Difficult suturing
ET-tube cuff noted to be collapsed shortly after closure completed.
Under direct vision, old ET-tube slowly pulled out over stylet and new one placed
Anterior Tracheal Injury Closed
ET-tube balloon transiently deflated and pt bagged c closure under irrigation fluid – no leak of air noted.
Strap muscle placed between esophageal and posterior tracheal repairs.
JP placed
Wound base irrigated and incision closed loosely.
Post-Op Course
Kept intubated for 1 week
Extubated at WRMC
Normal Ba Swallow
Some dysphagia – improving on discharge 3 weeks post-injury
}
Aerodigestive Injuries
~ 20% of neck injuries
- 10% Laryngotracheal
- 5% Hypo/Oropharyngeal
- 5% Esophageal
Presentation can be subtle, repair often difficult
{
Aerodigestive Case 2
Frag injury to left neck c cric performed in field
Primary & Secondary Survey performed:
Normal VS
GCS 3T
High left Zone 2 Lac
Left Flank Frag Wound
Left Thigh Wound
LLE NV Intact
XRs
Anatomy
OR Course
Stable pt c good airway control
Transcervical Trajectory at level of Pharynx/Larynx
No evidence of vascular injury
Wounds washed out & Pt sent to 31st CSH (ENT available)
CSH Course
Arrived stable
CT & Triple endoscopy revealed: pharyngeal laceration and swollen cords/larynx without visible laceration
Pharyngeal Injury Closed in 2 layers
Tracheostomy placed
Stable to LRMC c good final outcome
ENT Assistance helpful for aerodigestive injuries above C6 level
{
Aerodigestive Case 3
19 yo CPL sustains Frag wound during Operation Phantom Fury
C/O severe L Leg Pain.
P 90 BP 120/70 RR 20 T 34 C
GCS 15
O2 sat 96%
Anterior Neck Lac @ Cricoid level
R thigh lac
Large L hindfoot wound & L calf wound - tight with pain on passive range of motion, +DP, -PT
No hoarseness, SOB, Stridor
No crepitus, hematoma, or bruit
UEs NV Intact
XRs
Preop
IVF, Cefotetan administered
Taken to OR for fasciotomy/washout & neck exploration
Ready for Emergent Trach c Intubation
OR Course
Fasciotomies performed on L LE c Ligation of lacerated PT Artery & Veins
Hindfoot Wound Washed out & Splinted
Neck explored through collar incision
Anterior Tracheal Lac Visualized
Plugged c Fabric/Frag
FBs removed revealing Complex Tracheal Lac
No obvious post. lac seen through ant lac
Post frag not accounted for
Esophagus dissected out
No esophageal injury
? Last Frag ?
XR Obtained
Frag found in mobilized L Thyroid
Upper Tracheal Lac Closed
Tracheostomy placed through lower lac
Tracheostomy
- Place at 2-3rd Ring
- Higher assoc. c Stricture
- Lower assoc. c Tracheoinominate Fistulization
Post Op Course
Warm c normal VS at case’s end
Normal EGD & Re-washout at 332nd EMDG
No complications through LRMC
Case 3 Lessons
Fabric Contamination
Careful selection of priorities c multiple injuries
Don’t Fiddle/Flail – try different approach
Tracheostomy for complex injuries
Don’t be afraid to take some Thyroid
}