1. Approach to Penetrating Neck Trauma

2. A case… BK, 49 yo male self-inflicted stab wound to neck BK, 49 yo male self-inflicted stab wound to neck Found by EMS with steak knife nearby Found by EMS with steak knife nearby Unknown time down Unknown time down Unknown head strike, unknown LOC. Unknown head strike, unknown LOC. At scene patient was awake but non-communicative At scene patient was awake but non-communicative En route vitals stable En route vitals stable

3. A case…(cont.) PMH: unknown PMH: unknown PSH: unknown PSH: unknown Meds: unknown Meds: unknown All: unknown All: unknown Last meal: unknown Last meal: unknown

4. A case…(cont.) On arrival… On arrival… Vitals: T 98.0 BP 220/117 P 110 R 18 SaO2 100%RA Vitals: T 98.0 BP 220/117 P 110 R 18 SaO2 100%RA Gen: Awake and talking but not following commands. No stridor or hoarseness in voice. Gen: Awake and talking but not following commands. No stridor or hoarseness in voice. HEENT: PERRLA, EOMI. HEENT: PERRLA, EOMI. Neck: 2 cm laceration Zone II along anterior boarder of right SCM. Minimal bleeding from wound and a non-expanding hematoma was present. Neck: 2 cm laceration Zone II along anterior boarder of right SCM. Minimal bleeding from wound and a non-expanding hematoma was present. CV: Tachycardia, reg rhythm CV: Tachycardia, reg rhythm Pulm: CTA B/L Pulm: CTA B/L Abd: Soft, NT, ND. (+) BS. Abd: Soft, NT, ND. (+) BS. Rectal: Normal tone. No gross blood Rectal: Normal tone. No gross blood Ext: No gross deformities. Ext: No gross deformities. Neuro: No focal deficits. Spontaneous movement all 4 extremities. Neuro: No focal deficits. Spontaneous movement all 4 extremities.

5. A case…(cont.) CT head – negative CT head – negative CT neck – hematoma over R SCM. Trachea and esophagus intact. CT neck – hematoma over R SCM. Trachea and esophagus intact.

6. A case…(cont.) Taken to OR for wound exploration Taken to OR for wound exploration Findings: Underlying hematoma. Active bleeding from penetrating vessels of right SCM. No major vascular injury. No tracheal or esophageal injuries Findings: Underlying hematoma. Active bleeding from penetrating vessels of right SCM. No major vascular injury. No tracheal or esophageal injuries

7. Penetrating Neck Trauma Management algorithm is not universal and is constantly evolving Management algorithm is not universal and is constantly evolving Recommendations range from surgical exploration of everyone (Roon et al, 1979) to selective observation (Meinke et al, 1979) Recommendations range from surgical exploration of everyone (Roon et al, 1979) to selective observation (Meinke et al, 1979) Also depends on hospital’s availability of resources (ie. CTA/endoscopy) Also depends on hospital’s availability of resources (ie. CTA/endoscopy)

8. Penetrating Neck Trauma Two major types of injuries Two major types of injuries Major vascular injury Major vascular injury Esophageal/bronchial injury Esophageal/bronchial injury

9. Major Vascular Injury Strong suspicion: severe active hemorrhage, refractory shock, absent ipsilateral pulse, neuro deficit Strong suspicion: severe active hemorrhage, refractory shock, absent ipsilateral pulse, neuro deficit Weak suspicion: bruit, widened mediastinum, hematoma, diminished UE pulses, shock responsive to resuscitation Weak suspicion: bruit, widened mediastinum, hematoma, diminished UE pulses, shock responsive to resuscitation Evaluation: surgical exploration, CTA or angiogram Evaluation: surgical exploration, CTA or angiogram

10. Aeorodigestive Tract Injury Signs/symptoms: hemoptysis, hoarseness, odynophagia, SQ emphysema, hematemesis Signs/symptoms: hemoptysis, hoarseness, odynophagia, SQ emphysema, hematemesis Evaluation: Evaluation: Bronchoscopy Bronchoscopy Esophagoscopy or Gastrografin Esophagoscopy or Gastrografin swallow swallow

11. Management Algorithms Management depends on level of injury: Management depends on level of injury: Zone I – Thoracic inlet to cricothyroid membrane. Zone I – Thoracic inlet to cricothyroid membrane. Zone II – Cricothyroid membrane to angle of mandible Zone II – Cricothyroid membrane to angle of mandible Zone III – Angle of mandible to base of skull Zone III – Angle of mandible to base of skull  Also depends on depth (superficial to platysma should be irrigated, debrided, closed primarily)

12. Zone I Injuries Only 5% require operation Only 5% require operation CT angiogram or angiography widely advocated CT angiogram or angiography widely advocated Min invasive techniques preferred for repair (embolization, endovascular stenting) Min invasive techniques preferred for repair (embolization, endovascular stenting) Suspicion for aerobronchial injury? Suspicion for aerobronchial injury? Bronchoscopy/esophagoscopy/Gastrografin swallow Bronchoscopy/esophagoscopy/Gastrografin swallow

13. Zone III Injuries Surgery generally avoided due to difficult exposure Surgery generally avoided due to difficult exposure CTA if clinical evidence of vascular injury CTA if clinical evidence of vascular injury Min invasive techniques preferred Min invasive techniques preferred Bronch/esophagoscopy if evidence of aerodigestive injury Bronch/esophagoscopy if evidence of aerodigestive injury

14. Zone II Injury Highly controversial Highly controversial Wide spectrum of recommendations Wide spectrum of recommendations All agree that unstable patients or those with obvious vascular, tracheal or esophageal injury require surgical exploration All agree that unstable patients or those with obvious vascular, tracheal or esophageal injury require surgical exploration What about the stable patients? What about the stable patients?

15. Zone II Injury Surgical exploration for everyone? Surgical exploration for everyone? Pros: Pros: Easy exposure of vital structures Easy exposure of vital structures Low morbidity/mortality of procedure Low morbidity/mortality of procedure Discovery of subclinical injuries Discovery of subclinical injuries Better hemostasis Better hemostasis Cons: Cons: Cost (1981: estimated cost of exploration $1,930) Cost (1981: estimated cost of exploration $1,930) High percentage of negative explorations (50-68% in most series) High percentage of negative explorations (50-68% in most series)

16. Zone II Vascular Injury CTA, duplex U/S and angiography have all been advocated CTA, duplex U/S and angiography have all been advocated CT can help define trajectory of penetrating object (proximity to vital structures) CT can help define trajectory of penetrating object (proximity to vital structures)

17. Zone II Esophageal/Bronchial Injury Bronchoscopy/esophagoscopy/Gastrografin swallow (same as I and III) Bronchoscopy/esophagoscopy/Gastrografin swallow (same as I and III)

18. Zone II Recommendations Mandatory exploration and selective observation are both acceptable strategies Mandatory exploration and selective observation are both acceptable strategies Large academic centers more likely to have resources to evaluate and monitor patients 24 hours/day Large academic centers more likely to have resources to evaluate and monitor patients 24 hours/day

19. Operative Approach Exposure: Incision along anterior boarder of SCM (most common) Exposure: Incision along anterior boarder of SCM (most common) Arterial injuries: primary repair (preferred) vs. prosthetic grafts Arterial injuries: primary repair (preferred) vs. prosthetic grafts Venous injuries: ligate Venous injuries: ligate Tracheal/esophageal injuries: primary repair. Tracheal/esophageal injuries: primary repair. Place drain to avoid mediastinitis from enteric content leak Place drain to avoid mediastinitis from enteric content leak If both are injured a muscle flap placed between injuries can prevent TE fistula formation If both are injured a muscle flap placed between injuries can prevent TE fistula formation

20. References Ayuyao AM, Kaledzi YL, Parsa MH, Freeman HP. Penetrating neck wounds. Mandatory versus selective exploration. Annals of Surgery. 1985;202:563-567. Demetriades D, Theodorou D, Cornwell E, 3rd, et al. Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow doppler imaging. Archives of Surgery. 1995;130:971-975. Jurkovich GJ, Zingarelli W, Wallace J, Curreri PW. Penetrating neck trauma: Diagnostic studies in the asymptomatic patient. Journal of Trauma-Injury Infection & Critical Care. 1985;25:819-822. Klingensmith ME, Chen LE, glasgow SC, et al. The Washington Manual of Surgery, 5 th ed. Lippincott Williams & Wilkins. 2008; 375-377 Nemzek WR, Hecht ST, Donald PJ, et al. Prediction of major vascular injury in patients with gunshot wounds to the neck. Ajnr: American Journal of Neuroradiology. 1996;17:161-167. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. Journal of Trauma-Injury Infection & Critical Care. 1979;19:391-397. Saletta JD, Lowe RJ, Lim LT, et al. Penetrating trauma of the neck. Journal of Trauma- Injury Infection & Critical Care. 1976;16:579-587. Thomas AN, Goodman PC, Roon AJ. Role of angiography in cervicothoracic trauma. Journal of Thoracic & Cardiovascular Surgery. 1978;76:633-638. Tisherman SA, Bokhari F, Collier B, et al. Clinical Practice Guidelines: Penetrating Neck Trauma. Eastern Association for the Surgery of Trauma. 2008