1. NECK INJURIES
Yolandé Smit

2. Perspective 5 – 10% of all trauma cases
30% associated with injuries outside neck
Leading cause of immediate death is exsanguination
Esophageal injuries represents the most frequently missed injury and may be leading cause of delayed death
Compound difficulties in evaluation & Mx is the complicated anatomy - dense concentration of vital structures in a small space
Ongoing debate : mandatory vs selective exploration
Neck trauma can result in a spectrum of injuries and complications ranging from incidental to life threatening, incl hemorrhagic shock, acute neuroligal injury and airway compromise. Although usually obvious, unstable injuries can be extremey difficult to manage. Vascular and laryngeal injuries can rapidly compromise the airway, challenging the most experienced EP. Stable appearing pt can harbour insidious injuries associated with high morbidity and mortality if not recognized and treated. Practising EP must be familiar with the spectrum of injuries and subtle presentations of neck traumaRepresents 5-10% of all trauma cases presenting to the ED

3. HISTORY In 1552, Ambrose Pare ligated CCA. WW1 – mortality 60%
WW11 - mandatory exploration, mortality 47%
Continuous advances in anaesthesia and peri-operative management – mortality 6% for early vs 35% for late exploration
Currently 2-6%
In 1552, Ambrose Pare ligated both CCA and the jugular vein of a soldier with a traumatic neck injury at site of injury– he survived but developed aphasia and hemiplegia. Procedure of choice during WW1. Associated mortlity rates were as high as 60%. Significant neurological impairment was noted in about a third of patients, likely due to carotid ligation in those with an incomplete circle of Willis. During WW2,management changed to mandatory exploration of all penetrating wounds through platysma. Continuous advances in anaesthesia and peri-operative management since WW2 have improved outcome of these patients. Fogelman and Stewart reported in 1956 a mortality rate of 6% for early exploration vs 35% for delayed exploration. Present mortality for civilian wounds is 4-6%, with most deaths occuring from vascular injuries prior to arrival in ER

4. Mechanism of Injury
Penetrating
Blunt
Strangulation/ near-hanging

5. Penetrating Trauma (1) 5-10% of all traumatic injuries GSW Stab wounds
High velocity
Low velocity (50% lower incidence of significant lesions)
Stab wounds
Miscellaneous (shrapnel, impalement)

6. Penetrating Trauma (2) Incidence
Location
Arterial
Venous
Tracheolaryngeal
Pharyngoesophegeal
Spinal cord
Neuroligical, other
Thoracic duct
Percentage %
12.8
11.3
10.1
9.6 3
3.4
Total 1275 patients

7. Blunt Trauma
Vascular injuries are rare but represent one of the most under diagnosed injuries
Aerodigestive injuries are rare in comparison to penetrating injuries but can cause acute AW compromise and delayed complications
Causes:
Motor vehicle collisions
‘Clothesline’ injuries
Assault
Strangulation
Sports injuries

8. Strangulation Near hanging Manual Strangulation Ligature Strangulation
Complete/judicial
Incomplete
Typical
Atypical
Manual Strangulation
Ligature Strangulation
Postural Strangulation
Typical: knot midline directly under occiput which leads to a higher likelyhood of complete arterial occlusion. Manual and ligature: external compression independent of weight of victim. Postural seen in pediatric population: victims body weight compreeses anterior neck against firm object

9. Strangulation (2) Pathophysiology
High cervical fractures, complete cord transection, death
Venous congestion with stasis of cerebral blood flow leading to unconsciousness
Arterial occlusion with brain injury and death
Vagal reflexes contribute to fatal dysrythmias
Pulmonary sequelae
Compression of AW doesn’t play as significant role in incomplete hanging as does vascular occl
Pulmonary sequelae incl pulm oedema, bronchopneumonia, ARDS

10. Anatomy Three components Structural Visceral collumn
Respiratory layer
(trachea & larynx)
Alimentary layer
(pharynx & esophagus)
Endocrine layer
(thyroid & parathyroid)
Paired neurovascular bundle

11. Anatomy Two fascial layers Superficial fascia Deep fascia Beneath skin
Contains platysma
Deep fascia
Investing layer
Visceral layer
Prevertebral

12. Anatomy Prevertebral Fascia
Covers paraspinal structural components
Two layers/laminae: alar & prevertebral
Fans out to cover roots of brachial plexus and subclavian a
Axillary sheath
Attaches to transverse processes nad divides into 2 layers/laminae as it passes behind esophagus and in front of vertebral column: alar and prevertebral fascia

13. Anatomy Visceral Fascia
Forms visceral compartment
Pretracheal anteriorly
Buccopharyngeal and retroesophageal posteriorly
Portion enclosing the strap muscles a.k.a middle cervical fascia
Space between buccopharyngeal and prevertebral fascia
SPACE BETWEEN THE BUCCOPHARYNGEAL FASCIA AND THE PREVERTEBRAL FASCIA IS THE HIGHWAY FOR THE SPREAD OF BACTERIA AND GI CONTENTS AFTER AN ESOPHAGEAL INJURY. Pretracheal fascia attaches superiorly to thyroid and cricoid cartilages and extends into chest, where it blends with connective tissue between sternum and pericardial sac.

14. Anatomy Investing fascia
Envelopes Trapezius & SCM
Forms complete sheath of neck
Base of skull to sternum
Suprasternal space
Suprasternal space formed superior to manubrium where investing fascia divided into 2 layers attached to the ant and post surfaces of the manubrium. Encloses sternal heads of SCM’s, inf ends of ant jugular veins, jugular venous arch, fat and few lympnodes. Clinical significance: Trauma to this area can cause a bleeder and subsequently a large bulging above manubrium and even might distend down post to manubrium into sup mediastinum

15. Anatomy Carotid Sheath
Loose aggregation of connective tissue
Visceral compartment medial
SCM anterolateral
Prevertebral fascia posteriorly
Carotid sheath space: potential cavity which extends into mediastinum

16. Anatomy Fascial Layers: Importance
Superficial layer contains platysma: important surgical landmark
Tight fascial compartments may limit external hemorrhage from vascular injuries BUT easily compromises the airway
Danger space: mediastinits
Superficial layer: important surgical landmark as penetration has signified the need for surgical exploration.
Tight fascial compartments of neck structures may limit external hemorrhage from vascular injuries, minimizing the chance of exanguination, an apparantly beneficial effect that is countered, however, by the effectsof bleeding within these closed compartments, which frequently compromises the airway.

17. Anatomy Three Zones ZONE 1- thoracic outlet
Cricoid cartilage to sternal notch
ZONE 2- Central
Cricoid to angle of mandible
ZONE 3 - Skull base
Angle of mandible to base of skull
Divided into 3 zones inorder to aid to decision making for diagnostic tests and timing of surgery.
Zone 1 represents a dangerous area as vascular structures in this zone is in close proximity to the thorax.The bony thorax and clavicle act to protect zone 1 BUT this osseous shield also makes surgical exploration of root of nek difficult. Injuries to the right side is usually approached through a median sternotomy, while injuries to the left are often managed by left anterior thoracotomy. High mortality rate of 12%.
Zone 2 is most frequently involved region
Zone 3 protected by skeletal structures and is difficult to explore because of the skull base and th need to divide or diplace the mandible. Recognizing injuries to many of the cranial nerves exiting the skull base in zone 3 is importantant because these injuries may be indicitave of injuries to the great vessels due to close proximity

18. Anatomy Zones
Zones apply to neck anterior to anterior border of trapezius
Wounds to posterior triangle rarely associated with vascular, airway or digestive injury, except vertebral artery
Wounds through SCM or anterior triangle have high likelihood of injury
Decision making for diagnostic tests & surgical approach

19. Anatomy Cervical arteries

20. Anatomy Brachiocehalic A
4-5 cm in length
Ascend obliquely to right of sternoclavicular joint
Divides into right common carotid and subclavian aa

21. Anatomy Suclavian A Passes behind SCM, Jugular vein and Vagus nerve
Three branches
Vertebral
Internal mammary
Thyrocervical trunk
Courses post to anterior scalene than crosses first rib to become axillary artery

22. Anatomy Carotid A Common carotid has no branches
Bifurcates to external and internal carotids at superior border of thyroid cartilage
Internal – no cervical branches
External – 8 branches

23. Anatomy Vertebral A First branch of subclavian
Extra-osseous until entering the transverse process of C6 (V1)
Intra-osseous from C6 – C2 (V2)
Distal extracranial top of C2 to base of skull (V3)

24. INITIAL MANAGEMENT

25. Initial Management Airway (1)
Indications for immediate intubation
Apnoeic or near apnoeic patient
Comatose patient
Significant respiratory compromise (stridor, dysphonic with air hunger)
Rapidly expanding neck hematoma
Massive subcutaneous emphysema causing airway compression or distortion of trachea or larynx
Massive bleeding into airway

26. Initial Management Airway (2)
‘Wait-and-see’
If no immediate indication
Fastidious observation of clinical status
Equipment readily available
Prompt intubation if any evidence of expanding hematoma or enlarging neck sc emphysema
If no immediate indication: wait and see

27. Initial Management Airway (3)
Avoid BMV if possible
Oral intubation preferred
Without sedative in unconscious/ flaccid/near apnoeic patient
With sedation in uncooperative/agitated pt
RSI technique-of-choice
Difficult intubation anticipated:
‘Brutane’ technique
Ketamine 1-2mg/kg IV
Avoid BVM if possible because1) + pressure generated by BVM may increase airleak through a disrupted airway and cause massive subcut emphyseama with distortion of AW and further AW compromise 2) BVM may cause excessive neck movements in an oncooperative pt with increased bleeding from ‘contained hematoma.RSI technique of choice in uncooperative/agitated awake pt who does not have significant airway compromise, is “talking” and who could be easily “bagged” if necessary. If difficult intubation anticipated, do not use paralyzing NM agents. Alternative approaches include direct oral intubation using no drugs (brutane) or ketamine (does not impair gag reflex depress respiration.Rather not fentanyl/dormicum if suspected difficult airway: Insuficient sedation in uncooperative causes increased agitation with increased risk of disrupting any distorted airway or contained hematoma, while excessive sedation may result in loss of AW reflexes and neck muscle tone with potential aggravation of AW compromise

28. Initial Management Airway (4)
Surgical airway last resort
Cricothyrotomy preferred to tracheostomy:
Time
Position of neck
Bleeding
If laryngeal injury suspected
Consider awake local tracheostomy
Cricothyroidotomy for emergencies
Fibreoptic laryngoscope only if prepared to emergently obtain surgical airway
Needle cricothyroidotomy + jet insufflation may be acceptable to temporize
Retrograde intubation and blind nasal intubation is contra-indicated
Surgical AW last resort because displacement and disfiguration of topical landmarks causes increased risk of misadventure, however, surgical AW may become unavoidable if pt can not be intubated. Crycothyrotomy prefrred if no evidence of anterior hematoma overlying crycothyroid membane. Tracheostomy preferred if CI for cricothyrodotomy or impossible, or when probable/obvious disruption of trachea disruptionJet insufflation may be acceptable unless there is evidence of anatomical disruption of AW (AW leak). AW leak + positive pressure ventilation with insufflation cause increased sc emphysema with increased AW distortion + possibility of disruption of partially severed trachea + furtehr obscuration of landmarks

29. Initial Management Airway (5)
Pediatric considerations
Ideally with RSI
Fewer AW salvage techniques available:
Cricothyrotomy contra-indicated under 10
Emergency tracheostomy difficult
Degree of AW obstruction after blunt trauma to larynx inversely related to degree of calcification, putting children at highest risk
Cricothyrotomy CI due to small CTM and soft, poorly mineralized larynx

30. Initial Management Control bleeding
Local pressure
Proximal and distal control
Balloon tamponade with Foley’s catheter
Two catheters in supraclavicular zone1
Immediate ED thoracotomy with aspiration of air from RV if cardiac arrest immediately before or after arrival in ED
Local pressure: minimu amount of pressure should be applied to anywound to avoid any necessary compression of ipsilateral CA, as 10-30% of pt do not have sufficient collateral circulation to guarantee sufficient ipsilat collateral ant cerebral circulation blood flow. Pass Foleys through wound along wound tract indirection of apparent bleeding source. Inflate balloon with saline until bleeding stops or moderate resistance felt. If bleeding occurs through the central catheter lumen, try and pass catheter further. Clamp the catheter if catheter cannot advanced further and bleeding till occurs through lumen.Two catheters may be necessary in supraclavicular zone 1 with pleural violationand intrathoracic bleeding. First catheter is advanced into pleural cavity passed the bleeding source, the balloon is inflated and catheter pulled back firmly and held in place with arterial clamp to compress injured subclavian a against first rib. If external bleedinc continoues, a second catheter is passed into the proximal wound tract. Bleeding through the lumen suggests distal bleeding and catheter should be advanced, or further inflation of balloon and /or catheter clamping should be attempted

31. Initial Management Pitfalls
Do not probe wounds
Platysma penetration mandates evaluation in controlled fashion
Controversy about NGT
Tube may migrate from esophagus
Valsalva by patient may dislodge clot
Bloodstained

32. Initial Management Immediate Surgical Exploration
INDICATIONS
Severe active bleeding
Shock not responding to fluids
Rapidly expanding hematoma
Absent radial pulse
Evolving stroke

33. Initial Management Complete Primary Survey
Thorough examination
Vascular: Hard signs of vascular injury
Airway: Stridor hoarseness, dyspnoea, sc emhysema

34. Initial Management Secondary survey
Digestive tract
Dysphagia
Odynophagia
Hematemesis
Subcutaneous emphysema
Neurological: focal signs

35. Further Management

36. Further Management
If no indication for immediate surgical exploration, subsequent intervention based on :
clinical exam
Hard signs
Soft signs
No symptoms or signs
diagnostic testing
Evaluate stable pt for hard and soft signs of neurovascular and aerodigestive injury

37. Hard Signs Pulsatile bleeding Expanding hematoma
Not responding to resus
Absent distal pulses
Distal signs
Cold, pale limb
Stroke
Bruit
Airway obstruction
Stroke: neurological deficit suggestive of carotid or vertebral a injury

38. Soft signs Venous bleeding Stable hematoma Responding to resus
Diminished peripheral pulses
Proximity to major artery
Peripheral nerve deficit (brachial plexus)
Hemoptysis/hematemesis
Dysphonia/dysphagia

39. Diagnostic Strategies
Stable patient with hard signs:
exploration (diagnostic strategies to plan)
Stable patient with soft signs/ asymptomatic:
mandatory vs selective exploration (diagnostic strategies to aid in diagnosis)
Is physical examination reliable?
Consider:
Resources
Potential for injury
Ability to serially exam
Consequences of missed injury
Literature remains divided between those who do and those who do not believe that physical examination is reliable. Some centres advocate mandatory exploration for patients with no signs or soft signs, citing the unreliabilty of physical examination. Others prefer a selective protocol using either diagnostic testing coupled with physical examination or only serial examinations. Role of selective management has been to reduce – neck explorations while maintaining a low mortality rate.

40. Diagnostic strategies
X-Rays
Chest: PT/HT, widened mediastinum, mediastinal air, elevated hemidiaphragm, FB
Neck: prevertebral air or swelling, sc air, FB
Gastrograffin swallow
All penetrating neck injuries due to high incidence of occult injuries
Endoscopy
If swallow (-), enhances sensitivity for penetrating esophageal injury

41. Diagnostic Strategies
Arteriogram
Diagnostic
To plan surgery
Therapeutic
Laryngoscopy/ bronchoscopy
Hemoptysis/ hoarseness/ sc emphysema/ laryngeal tenderness or deformity
CT neck
Useful for evaluating laryngeal injuries
May play a role in the future as screening modality in diagnostic evaluation of AW & vascular injuries in asymptomatic pt

42. Diagnostic strategies
Airway/resus/assessment
Stable
Unstable
Active hemorrhage
Expanding hematoma
Evolving stroke
Zone 1
Zone 2
Zone 3
Swallow
Endoscopy
Arteriogram
Arteriogram
Swallow
Endoscopy
Explore + - - +
Observe
Explore
Embolize
Observe