1. Neck Trauma

2. §Penetrating trauma §Blunt trauma §Near - Hanging & Strangulation

3. Penetrating Trauma Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation

4. Pathophysiology Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous

5. Organ System Classification §Vascular ( most common ) §Pharyngoesophageal §Laryngotracheal §Others ( cranial nerve, thoracic duct, brachial plexus, spinal cord….

6. Vascular Three pathophysiologic mechanisms §External hemorrhage §Extending soft tissue hematoma, distort or obstruct the airway §Disruption of cerebral perfusion ( CVA )

7. Pharyngoesophageal §Rarely causes any immediate consequence §Delayed diagnosis can lead to serious soft tissue infection, mediastinitis and sepsis

8. Laryngotracheal §Small puncture wound §Airflow away from respiratory tree §Obstruction of airway

9. Wound Location Classification §Anterior (Sternocleidomastoid muscle ) §Posterior §Anterior l Zone 1 ( below cricoid cartilage ) l Zone 2 ( between the cricoid cartilage and mandible angle ) l Zone 3 ( above mandible angle )

10. Management of Penetrating Trauma Stabilization §Critically injured patient l Rapidly assessing vital functions and the area of injury l Performing stabilizing interventions l Initiating a diagnostic workup l Definitive care §No immediate life threat l Violates the platysma ( explore at OR ) * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order

11. Airway §The risk of spinal cord injury is minimal §Cervical cord injury in a gunshot wound victim when intubation has never been reported §Preintubation radiography is significant

12. Airway General §Most difficult management dilemma: awake patient with impending airway obstruction §Preoxygenation is important # Comatous patients & patients in respiratory distress require immediate intubation # It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED )

13. Airway Method §Oral & nasal intubation with or without endoscopic guidance or muscle relaxants §Percutaneous transtracheal ventilation ( PTV ) §Surgical airway

14. Airway Method §PVT l Airway remains unprotected & uncomfortable in conscious patient l Temporary intervention l Complication and contraindication 1. Significant airway obstruction & penetrated airway 2. Subcutaneous emphysema, pneumothorax

15. Airway Method §Surgical Airway l Last resort ( direct injury to the airway is exception ) l cricothyrotomy l Tracheostomy or even intubation via the wound

16. Hemorrhage External hemorrhage §Direct pressure §Blindly clamping bleeding vessels is avoided §Quick transfer to the operating room Inter Hemorrhage §Airway compromised §Zone 1 injury result in hemothorax ( thoracostomy )

17. Definitive Management of Penetrating Trauma Unstable patient Immediate transfer to the OR Stable patient l General l Mandatory exploration l Selective Approach

18. Definitive Management Stable Patient §General l Lateral neck film l CXR ( especially in zone 1 injuries ) l NG tube should not be inserted l Prophylactic antibiotics §Mandatory exploration §Selective Approach l A selective method reserves operative intervention for patients with clinical signs of significant injury

19. Clinical Findings:Require Surgical Intervention Using a Selective Approach §Expanding or pulsatile hematoma §Presence of a bruit §Horner syndrome §Subcutaneous emphysema §Air bubbling through wound §Hemoptysis or blood - tinged saliva §Shock or active bleeding §Absent peripheral pulses §Respiratory distress Others are observed & undergo various diagnostic studies

20. Other Diagnostic Studies §Bronchoscopy §Esophagography §Esophagoscopy §Angiography # Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies

21. Disposition of Penetrating Neck Trauma No indication for surgery ==> admission for at least 24 hrs

22. Blunt Trauma §Rare, compared with penetrating trauma §Motor vehicle crash or an assault §Off - road vehicles

23. Classification of injuries §Larygotracheal §Pharyngoesophageal §Vascular : delayed dissection or thrombosis ( CVA )

24. Four recognized mechanisms by which thrombosis can occur §A direct blow to the neck §A blow to the head that causes hyperextension and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels §Blunt intraoral trauma §Basilar skull fracture

25. Spinal column and spinal cord injuries are more prevalent in blunt trauma

26. Clinical Feature Physical findings may be lacking, it is important to elicit symptoms 1.Dysphagia, odynophagia 2.Voice quality 3.Aphonia, muffled voice ( serious injury )

27. Management of Blunt Neck Trauma Whether the patient has laryngotracheal injury?

28. Definitive Management General l C - spine X-ray l CXR Additional Studies l Laryngotracheal l Vascular l Pharyngoesophageal

29. Additional Studies §Laryngotracheal l Plain radiographs l CT l endoscopy ( fiberoptic bronchoscopy ) ( Consult chest surgeon or ENT ? ) §Vascular l Angiography l Color Flow Doppler ultrasound §Pharyngoesophageal l Threshold for performing diagnostic studies should be low l Esophagram & esophagoscope ( Consult chest surgeon )

30. Disposition of Blunt Neck Trauma §Laryngeal injuries do not require immediate repair §Tracheal injuries should receive prompt surgical attention

31. Near - Hanging & Strangulation Classification of Strangulation §Hanging ( most common ) §Ligature strangulation §Manual strangulation §Postural strangulation

32. Clinical Features §Superficial & Deep Neck §Respiratory (delayed mortality) l Bronchopneumonia l Aspiration pneumonitis l Delayed airway obstruction l ARDS §Neuro psychiatric

33. Management §Spinal cord injury is very rare §Phenytoin: useful in preventing ischemic cerebral damage §Naloxone §Ca 2+ channel blocker

34. Summary Structured approach to these patients, regardless of mechanism is essential to optimize outcome & avoid catastrophe