1. Penetrating Neck Trauma
This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation
In Slide Show, click on the right mouse button
Select “Meeting Minder”
Select the “Action Items” tab
Type in action items as they come up
Click OK to dismiss this box
This will automatically create an Action Item slide at the end of your presentation with your points entered.
Penetrating Neck Trauma
Nate Whittaker
12/13/07

2. Penetrating Neck Trauma
Intro
Anatomy
ABCs
Physical Exam
Diagnosis & Management

3. Penetrating Neck Trauma
Missile or sharp object penetrating the skin and violating the platysma (GSW, Stab, Puncture wounds, and Impalement Injuries).
30% of cases are accompanied by injury outside of the neck zones
5-10% of all traumas presenting to the ED

4. Penetrating Neck Trauma
Higher mortality rates with injuries to large vessels (carotid or subclavian arteries and veins)
Civilian
mortality rate
ranges from
3-6%

5. Extent of Tissue Damage
Kinetic Energy = mass x velocity2
Low-energy weapons - hand-driven weapons (knives, ice picks)
Medium-energy (handguns)
High-energy weapons (military assault weapons) >2500 ft/s
direct impact VS tissue displacement from temporary cavitation

6. Anatomy
Anterior Triangle - middle line of the neck, anterior margin of the scm, the mandible.
Posterior Triangle
– posterior margin
of scm, trapezius,
clavicle

7. Anatomy

8. Anatomy
Zone I – between the clavicle/suprasternal notch and the cricoid cartilage. Includes the proximal common carotid, vertebral, and subclavian arteries and the lungs, trachea, esophagus, thoracic duct, major cervical nerve trunks.

9. Anatomy
Zone II - between the cricoid cartilage and the angle of the mandible. Includes the internal and external carotid arteries, jugular veins, larynx, pharynx, esophagus, recurrent laryngeal nerve, spinal cord, trachea.

10. Anatomy
Zone III - between the angle of the mandible and the base of the skull. Includes the distal extracranial carotid and vertebral arteries, the uppermost jugular veins and the pharynx.

11. Anatomy
Platysma – the first muscle layer under the skin of the anterolateral neck
If clearly intact, local wound repair is all that is required
If violated, STOP exploration and consult surgery.
Further exploration may
dislodge a clot, increase
bleeding, or cause
an air embolism

12. ABCs

13. ABCs

14. Early Airway Intervention
Acute Respiratory Distress
Compromise from blood/secretions
Massive SQ emphysema
Tracheal Shift
MS alteration

15. Airway 25-30% of neck trauma need an emergent airway
40% are never intubated
Consider the progression of airway distortion with air or blood transecting through fascial compartments
Unnecessary Intubation VS waiting for a difficult intubation with respiratory distress and a distorted airway

16. Airway RSI Gum Elastic Bougie
Blind Nasotracheal – perceived high failure and complication rates
Fiberoptic
Retrograde tracheal intubation
Cricothyrotomy
Tracheostomy
                                      

17. LA County, Level I trauma center, 1993 -1996
Emergency airway management in penetrating neck injury. Mandavia DP, Qualls S, Rokos I Ann Emerg Med. Mar 2000;35(3):221-5.
LA County, Level I trauma center,
748 cons. patients with penetrating neck injury
82 (11%) required immediate airway management
24 excluded because of out-of-hospital traumatic arrest or out-of-hospital intubation
58 patients - 39 RSI with SUCC, 100%
5 comatose - orotracheal intubation w/o paralysis
2 - emergency tracheostomies
12 fiberoptic intubations by ENT - 3 failedRSI
47 (81%)total orotracheal intubations

18. Blind nasotracheal intubation for patients with penetrating neck trauma. Weitzel N, Kendall J, Pons P. J Trauma. May 2004;56(5):
Denver, Colorado,
240 patients with penetrating neck trauma
89 (37%) required emergent airway management
40 (17%) prehospital blind nasotracheal intubation
Success rate - 90%
Mean # of attempts was 1.16 (range, 1-4)
Paramedics very experienced at blind nasotracheal intubation

19. Blind intubation through the wound failed x 3 2/2 constant blood blow
Use of a gum elastic bougie (GEB) in a zone II penetrating neck trauma: a case report. Steinfeldt J, Bey TA, Rich JM. J Emerg Med 2003;24:267-70
Self inflicted 5cm deep slash wound in zone II w/ transection of his pharynx
Blind intubation through the wound failed x 3 2/2 constant blood blow
Bougie used to intubate trachea with confirmatory clicking on tracheal rings
ET tube successfully placed over bougie into trachea

20. Cricothyrotomy Favored surgical back up if RSI fails
Have kit opened and neck prepped before RSI in tenuous circumstances
Risk of disrupting stable hematoma in some trauma patients  obscuring operative field and significant hemorrhage
If integrity of larynx is questionable, tracheostomy may be the best
option

21. Airway C-spine – maintain the best you can
No reports of unstable c-spine injuries from stab wounds (not enough force)
GSW – instability = fx in 2 columns, requiring the bullet to traverse the spinal cord  neurological symptoms
Airway takes priority
Remove the collar
Use in-line cervical
traction for c-spine
stabilization.

22. Breathing
Possible to have injury to both the base of the neck and thorax – Zone I
High-Flow Oxygen/ Pulse OX
Difficulty ventilating could be an upper airway or thoracic injury
Unequal breath sounds or
asymmetric chest movement
= pneumo/hemothorax
Watch for tracheal deviation
– tension pneumothorax

23. Circulation Hard signs of Vascular Injury
Bruit or Thrill
Expanding or Pulsatile Hematoma
Pulsatile or Severe Hemorrhage
Pulse Deficit
Soft signs of Vascular Injury
Hypotension and Shock
Stable, nonpulsatile hematoma
Central or Peripheral nervous system ischemia
Proximity to a major vascular structure

24. Circulation Control active bleeding with direct pressure
2 Large Bore IVs and judicious fluid resuscitation
Do not clamp bleeding vessels as this can cause additional vascular and/or nerve damage
Avoid NG tubes initially as gagging may dislodge a clot  hemorrhage
Mild Trendelenburg position to decrease the risk of air embolization in venous injuries

25. Circulation The EJ vein can be tied off w/o adverse affect
                                                                                                                                                                      
The EJ vein can be tied off w/o adverse affect
Do NOT remove impaled objects
Deep Zone I injuries that do not stop bleeding with pressure may be from a subclavian artery injury – consider temporizing with a foley catheter

26. Cape Town, South Africa 07/04 – 06/05 220 penetrating neck traumas
 Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma.  Navsaria P, Thoma M, Nicol A. World J Surg. Jul 2006;30(7):1265-8
Cape Town, South Africa 07/04 – 06/05
220 penetrating neck traumas
17/18 successfully txed with foley tamponade
Foley filled with 5 ml of h20 or until resistance felt
Zone I – 3, Zone II – 8, Zone III – 1, Posterior triangle – 5

27. Disability Spinal Cord Phrenic Recurrent Laryngeal
Cranial Nerves IX-XII
Brachial Plexus
Focal neurological deficits from damage to the carotid or vertebral artery  CNS Ischemia

28. Exposure
Expose the entire body, looking for evidence of additional trauma (30 % of penetrating neck trauma)

29. ED Stand-up

30. Who goes emergently to the OR ?
Absolute Criteria:
Shock
Uncontrolled Bleeding
No Radial Pulse
Rapidly Expanding or Pulsatile Hematoma
Respiratory Distress
Relative Criteria:
Air Bubbles from Wound
Hemoptysis
Crepitus

31.                                                                       
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
Physical Exam
Controversial how much weight should be placed on physical exam
Regardless, the more we gather from the PE, the more appropriate and timely our w/u and management will be
Demetriades et al, Los Angeles (OR full, stock in PE, chart)

32. Physical Exam Vascular – 25 – 50% of cases
Active Bleeding (w/ direct pressure)
Degree
Hypotension
>100, 60-90, <60
Peripheral Pulses (brachial, radial)
Diminished, absent
Bruit – heard in 50% of carotid injuries
where
Hematoma (size, expanding?)

33. Physical Exam Possible Vascular Injuries Pseudoaneurysm Dissection
Arteriovenous Fistula
Complete Transection
Thrombus Formation  Stroke

34. Physical Exam Larynx/Trachea – 10 % of cases
Hemoptysis (ask pt to cough)
Air bubbling though the wound (ask pt to cough)
Subcutaneous emphysema
Crepitation
Hoarseness
Trachea Midline

35. Physical Exam
Esophagus – 5% of cases – the most missed injury in penetrating neck trauma
Hematemesis
Pain on Swallowing sputum
Subcutaneous emphysema
Drooling
Mortality Rates reported as high
as 17%, if detection is delayed >12 hours
Mediastinitis
Occult Injury  bad outcome, but usually accompanied by suspicious signs/symptoms

36. Physical Exam
Nervous System - Approximately 10% have a spinal cord or a brachial plexus injury
GCS (eye, verbal, & motor responses)
Localizing Signs
Pupils
CNs
Facial
Glossopharyngeal (midline palate elevation)
Recurrent laryngeal –X- (horseness, good cough)
Accessory (shoulder shrugging)
Hypoglossal (tongue protrusion)

37. Physical Exam Nervous System Horners Syndrome (myosis, ptosis)
Sympathetic chain goes up the Carotid
Spinal cord – moving all 4 ext.
Brachial Plexus
Median – fist
Radial – wrist ext
Ulnar – abduction/adduction of fingers
Musculocutaneous – forearm flexion
Axillary – arm abduction

38. Physical Exam
Obvious signs/symptoms suggestive of major vascular or aerodigestive injuries require emergent or urgent operative intervention

39. Who goes emergently to the OR ?
Absolute Criteria:
Shock
Uncontrolled Bleeding
No Radial Pulse
Rapidly Expanding or Pulsatile Hematoma
Respiratory Distress
Relative Criteria:
Air Bubbles from Wound
Hemoptysis
Crepitus

40. Diagnosis & Management
Institution, Resource, and Surgeon dependant
All hemodynamically unstable patients or those with obvious aerodigestive injuries should go immediately to the OR
Everybody gets a an AP CXR & a Lateral/AP Neck
Type and Cross
Consider LA, base
deficit, or bicarb

41. Diagnosis & Management
Historically, after WWII, routine surgical exploration of Zone II penetrating wounds was accepted
Studies in the 1980s demonstrated a high rate of negative exploration encouraging a more selective approach to surgical management
Since then, the greatest controversy has been over how to w/u stable Zone II trauma pts without evidence of Aerodigestive injury

42. Diagnosis & Management
Unless hemodynamically unstable or there is evidence of aerodigestive tract injuries, surgeons prefer the selective approach in Zone I & III, given difficulty of exposure
Operative management of Zone I may require a median sternotomy or a thoracic approach and Zone III may require disarticulation of the mandible or resection of the styloid or mandible angle.

43. Diagnosis & Management
                                               
Diagnosis & Management
Three major structures to evaluate:
Vascular (namely arterial)
4 Vessel Angiography (Gold Standard)
Duplex Ultrasonography
90-95% sensitivity in experienced hands to injuries requiring intervention compared to >99% w/ Angio
Esophagus
Esophagoscopy
Esophagram
Varying sens (90%), spec, & accuracy – Recommended to use both – ( almost 100% sens. Per 1 study)
Airway
Laryngoscopy
Tracheoscopy/Broncoscopy (Gold Standard)

44. Diagnosis & Management
Britt LD: Neck Injuries: Evaluation and Management, Moore EE, Feliciano DV, Mattox KL (eds): Trauma, 5th ed New York, NY: McGraw-Hill, 2004, p. 450

45. Pts received both studies (HCTA) Sensitivity 90%, Specificity 100%
 Penetrating injuries of the neck: use of helical computed tomographic angiography. Munera F, Cohn S, Rivas LA. J Trauma. Feb 2005;58(2):413-8
University of Miami
24 – month prospective study with 60 pts with penetrating neck trauma referred for conventional angiography (vertebral and carotid)
Pts received both studies (HCTA)
Sensitivity 90%, Specificity 100%
single lesion missed from a technical error
PPV 100%, NPV 98%

46. 27- month prospective study Sensitivity 100%, Specificity 98.6%
Penetrating injuries of the neck: use of helical computed tomographic angiography. Munera F, Cohn S, Rivas LA. J Trauma. Feb 2005;58(2):413-8
2nd Study with HCTA
27- month prospective study
146 pts
Sensitivity 100%, Specificity 98.6%
PPV 92.8%, NPV 100%
Outcomes with 46 day f/u was the standard of reference
27 pts (15.6%) with vascular injuries
Arterial occlusion-14, pseodoaneurysm-8, av fistulas-4, partial thromboses-2 detected

47. The 2 studies also found associated lesions in 81 pts
Penetrating injuries of the neck: use of helical computed tomographic angiography. Munera F, Cohn S, Rivas LA. J Trauma. Feb 2005;58(2):413-8
The 2 studies also found associated lesions in 81 pts
C-spine fxs – 28
Mandibular or Facial fxs – 25
Aerodigestive injuries – 4
Hematoma compressing airway – 22
Hematoma w/ spinal cord
compression – 3
No esophageal or
airway injuries missed

49. CT Angiography in Penetrating Neck Trauma Reduces the Need for Operative Neck Exploration. Woo K et al. American Surgeon. 71(9):754-8, 2005 Sep.
Conclusions from this study recommend HCTA as a screening test, as the tract of injury can be seen
1. Tract seen, no injuries  NO surgery
2. Injury to vascular or aerodigestive structure  surgery
3. Indeterminate scan  further eval.

50. HCTA/MDCT Limitations
Artifact from bullet fragments or other metallic foreign bodies and shoulders of large pts
Inability to perform endovascular therapy simultaneously
Not in real time

51. HCTA/MDCT Benefits Less expensive Don’t have to call in the angio team
Less Invasive
3-D reconstruction
Can see trajectory
of penetrating
injury and proximity
to structures

52. Penetrating neck trauma
Diagnostic Algorithm for Penetrating Neck Trauma
Penetrating neck trauma
Stable
Unstable
-Hemorrhagic Shock
-Evolving Stroke
-Expanding Hematoma
-Unstable Airway
Physical Exam
AP Chest x-ray
AP/lateral soft tissue neck x-ray
Surgical Exploration
Normal
Abnormal
III II I
Observation
(Maybe)
Zones I, II, III - Head CT?
MDCTA/Conventional Angiography
Vascular Injury
Suspicion of
Aerodigestive
Injury
Surgical Exploration
Esophagoscopy/Esophagram
Laryngoscopy/Bronchoscopy
Injury
No Injury
Rathlev NK, Mendozen R, Bracken ME. Evaluation and Management of Neck Traum. Emergency Med Clin N Am 25 (2007)
Surgical Exploration
Observation

53. Moonlighting
Soooo…. What do you do when you are moonlighting in Marlette and a Penetrating Neck Injury walks in?
Is the platysma violated?
What would you do even if you had a HCT scanner and you found an injury?
What is your on call surgeon comfortable with?

54. Summary ABCs RSI with a back up (cric.) Does it penetrate the platysma
All unstable patients immediately go to the OR
Good Physical Exam
Don’t miss the esophageal Injury
If stable, consider MDCTA as a screening evaluation

55. References
Britt LD: Neck Injuries: Evaluation and Management, Moore EE, Feliciano DV, Mattox KL (eds): Trauma, 5th ed New York, NY: McGraw-Hill, 2004, p. 445
Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med. Mar 2000;35(3):221-5
Weitzel N, Kendall J, Pons P. Blind nasotracheal intubation for patients with penetrating neck trauma. J Trauma. May 2004;56(5):
Steinfeldt J, Bey TA, Rich JM. Use of a gum elastic bougie (GEB) in a zone II penetrating neck trauma: a case report. J Emerg Med 2003;24:267-70
Tintinalli, J.E., Kelen, G.D., and Stapczynski, J.S. (Eds.) (2004) Disaster Medical Services: Chapter 258. Emergency Medicine: A Comprehensive Study Guide, 6th Edition. McGraw-Hill.
Levy D. Neck Trauma, Emedicine. Available at:
Cheng E. Penetrating Neck Trauma, Emedicine. Available at:
Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. Feb 2005;58(2):413-8.
Woo K et al. CT Angiography in Penetrating Neck Trauma Reduces the Need for Operative Neck Exploration. American Surgeon. 71(9):754-8, 2005 Sep.
Kuzniec S, Kauffman P, Molnar LJ, et al. Diagnosis of Limb and Neck Arterial Trauma using Duplex Ultrasonography, Cardiovasc Surg. 1998:6:358-66
Rathlev NK, Mendozen R, Bracken ME. Evaluation and Management of Neck Traum. Emergency Med Clin N Am 25 (2007)
Collucciello S. Neck Trauma (Soft Tissue Injuries). EMRAP: Emergency Medicine Reviews and Perspectives 2006 Aug.