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

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

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

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

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

OBSERVE CONSIDER

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

Foley – Muller, Injury 1994

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

Operative Technique

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

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

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

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

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

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

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

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

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

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

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

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