Penetrating neck trauma Noura AlAyedh Abeer AlGhamdi Doha Marenga

overview Definition Epidemology Etiology Pathophysiology Presentaion Hard signs of air way injury Evalaution Indication of surgical evaluation Investigation Managment

definition Penetrating neck trauma involves a missile or sharp object penetrating the skin and violating the platysma layer of the neck. This includes gunshot wounds, stab or puncture wounds, and impalement injuries

Anatomy zones Anatomy: Zones I – III Zone I: sternal notch > cricothyroid membrane Zone II: cricothyroid membrane > angle of mandible Zone III: angle of mandible > skull base *Zone I is treated like thoracic injury

Epidemiology Penetrating neck trauma represents approximately 5-10% of all trauma cases that present to the emergency department. About 30% of these cases are accompanied by injury outside of the neck zones as well. 1.Gun shot (GSW): 45% 2. Stab (SW) 40% *Structures injured: (40% no significant damage) Major vein 15-25% Major artery 10-15% Digestive tract (pharynx, esophagus) 5-15% Respiratory tract (larynx, trachea) 4-12% Major nerves 3-8%

The objects causing these injuries can be divided into: Etiology Penetrating neck injuries, like any trauma, may be classified as intentional or nonintentional. The objects causing these injuries can be divided into: stabbing instruments (eg, knives, cutting instruments, puncturing objects, impaling objects) shooting instruments (eg, missiles, projectiles).

Pathophysiology Two factors in the mechanism of injury in penetrating neck trauma determine the extent of damage to the tissue: Weapon characteristics The amount of kinetic energy delivered by the wounding agent has to be considered together with its interaction with the involved tissue. Location of injury and human tissues involved Tissue injury results from either a direct impact by the penetrating projectile or tissue displacement from temporary cavitation. Wound sites and, if present, the wounding agent in the neck provide an indication of the likely injury complex. Kinetic energy (KE) is described by the following equation: KE = 1/2 mass X velocity (squared).

Dysphagia –> Tracheal and/or esophageal injury Presentation Evidence of significant injury to vital structures of the neck may be indicated by the following clinical manifestations: Dysphagia –> Tracheal and/or esophageal injury Hoarseness –> Tracheal and/or esophageal injury (especially recurrent laryngeal nerve) Oronasopharyngeal bleeding –> Vascular, tracheal, or esophageal injury Neurologic deficit – Vascular and/or spinal cord injury Hypotension –> Nonspecific; may be related to the neck injury or may indicate trauma elsewhere

hard signs of airway injury Subcutaneous emphysema –> Tracheal, esophageal, or pulmonary injury Air bubbling through the wound Stridor or respiratory distress –> Laryngeal and/or esophageal injury

hard signs that strongly indicate vascular injury Hematoma (expanding) –> Vascular injury Active external hemorrhage from the wound site –> Arterial vascular injury 3. Bruit/thrill –> Arteriovenous fistula 4. Pulselessness/pulse deficit ->Distal ischemia (neurologic deficit in this case)

secondary survey (complete history & physical examination). evaluation (ABC). secondary survey (complete history & physical examination). Mechanism of injury? Which zone? Depth of the wound (through platysma)? Transcervical Workup (next slides)

Investigation

Laboratory Studies Hemoglobin concentration: is useful to evaluate for the immediate need for transfusion and to document the starting point for future comparison. A toxicologic screen: is indicated for the patient with an altered sensorium. This is important to help differentiate the altered sensorium of intoxication from a neurologic etiology following penetrating neck trauma with an arterial injury component.

Cervical anteroposterior and lateral radiography Imaging Studies Cervical anteroposterior and lateral radiography (evaluate for vertebral bony injury; retained foreign bodies; and foreign body deformity, location, size, and number.) Four-vessel cerebral angiography (Indicated with clinical evidence of significant vascular injury (ie, hard signs) in zone I and zone III, as well as in selectively managed zone II injuries) CT / CT angiography MRI

Diagnostic Procedures Direct laryngoscopy : For evaluation of oropharyngeal and tracheal injuries Flexible bronchoscopy : For delineation of tracheal and bronchial injuries Esophagoscopy: Flexible esophagoscopy can be used to detect an esophageal injury with less risk of procedure-related complications than rigid esophagoscopy

>>> Mandatory Exploration Management Unstable: Airway injury , Hemodynamic instability, uncontrolled bleeding, evolving CVA >>> Mandatory Exploration

Cont. 2.Stable w/ Symptoms: Hematoma, hemoptysis, hematemesis, dysphagia, dysphonia, peripeheral neuro deficit, subcutaneous air >>> CTA in all Selective testing: endoscopy, esophagraphy, arteriography zones 1&3 Mandatroy exploration?

3. Stable w/out symptoms: observe >12h CTA in all Artiography & Esophagraphy in zone 1 Exploration?

Indications of surgical exploration patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. The type of incision depends on the neck zone and the structures at risk for injury.

Carotid artery injuries Vertebral artery injuries Jugular vein injury Cont.. The following specific injuries must be confirmed and treated during neck exploration: Carotid artery injuries Vertebral artery injuries Jugular vein injury Laryngotracheal injuries Esophageal injuries Nerve injuries Thoracic duct injuries Thyroid injuries

Thank You!!