1. Penetrating Neck Trauma (Made Easy?)
Tim Hardcastle
Trauma Surgeon
Durban – South Africa

2. Introduction
Penetrating neck injury common in South Africa and the USA
TBH >500 per year
DBN >200 per year
Less common in UK and Europe
Fear and trepidation: limited experience
Approaches are different to H&N surgery

4. Mechanism of Injury Most cases will be stabs and GSW
Both can cause major injury
Bullets often more injurious
May be combined blunt / penetrating injury – impaled objects

5. Anatomy
Dense collection of neuro-vascular and aerodigestive structures
Multiple fascia layers
Extend upward into the skull
Extend downward into the mediastinum

6. Diagnostic Approach Does it penetrate? All – unstable Zone 1 & 3
OPERATE
Zone 1 & 3
Image
Attempt to use non-operative options
Zone 2
2 Philosophies
Explore all
Image and explore selectively*
*BJS 1990: 908; World J Surg 2008: 2716; EMJ 2009: 106

7. OBSERVE
CONSIDER

9. Resus Room Don’t probe non-bleeding wounds
Be very wary with muscle relaxants
Fingers and Foleys are your friend
No blind clamping
Haematomas compress airways
Surgeon must be ready for surgical airway when Anaesthetist intubates

10. Foley – Muller, Injury 1994

11. Management of the airway
Preferably in the OR if unstable
Non-drug assisted intubation best
Use a cardio-stable agent: Etomidate*
Have a difficult airway trolley
Fibrescope
Gum elastic bougie
Surgical crico-kit (Scalpel and no 6ETT)
LMA as back-up
Good suction
Surgeon Scrubbed and ready
*Hardcastle, SAJCC July 2008

12. Operative Technique

13. Zone 1 Drape widely If in doubt – sternotomy
High ANT for proximal L-SCA
Beware of the BCV
Oversew
Get proximal control

14. Zone 1
Access to:
BCA
L-CCA
L-SCA; actually better than HLAT
Heart
Oesophagus below T1 better via R-Thoracotomy, also trachea/bronchi

15. Zone 2 Standard neck incision Drape for extensions
Position is everything
Good haemostasis
Loop readily
Use the plains

17. Vascular injury Proximal and distal control Heparinise
Debride and mobilise
Can often repair primarily
Vein grafts are best
PTFE is acceptable conduit
Veins can be readily ligated

19. Aero-digestive injury
Repair true oesophagus – below C6
Pharynx can be safely drained
Avoid trachy with oesophagus injury
Muscle interposition for combined tracheal and oesophageal injury
Single layer absorbable repairs
Drain – (not closed suction) for 8-10 days; place intra-op NGT
Trachea – interrupted sutures; air tight

20. Zone 3 Tiger country! I don’t like the jaw transection!
Try muscle releases first
Bite-block in mouth gives extra space
High Carotid – repair distal first
Consider ligation if good back-pressure
Watch out for the hypoglossus – at the carotid bifurcation

21. Other options Endovascular therapy stents and coils
Requires catheter expertise or ready access to interventional radiology
BJS 2003: 1516 / J Vasc Surg 2008: 739 / Eur J Vasc Endovasc Surg 2000: 489 & 2008: 56 / J Endovasc Ther 2001: 529

22. Closure Sternotomy standard closure Neck Leave a mediastinal drain
Close the platysma
Close the skin
Drain via a separate site
Trachy via a separate incision if needed

23. Post-operative care ICU only if intubated / trachy Mobilize early
LMWH post-op
Contrast study on D5 - 7
NGT for early feeding
Extubate around D3 if trachea repaired
Remove drains once tolerating oral diet
Beware swallowing incoordination is common
Only 3 doses of prophylactic AB

24. Outcome Non-operative Aerodigestive injury Vascular
Minimal missed injury, seldom clinically significant
Aerodigestive injury
Most will heal; leaks can be controlled fistula
Time to repair determinant
Vascular
Repair within 24 hours good outcomes*
*Du Toit et al J Vasc Surg 2003: 257

25. Conclusions Penetrating injury to the neck can be challenging
May be unfamiliar territory to many General Surgeons
Know the approaches
Know the anatomy
Most patients will do well if principles followed

26. ?