1. Penetrating and Blunt Neck Injuries “Deadly Missed Injuries”
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics

2. Types of Injury - Penetrating
40% do not involve important structure
GSW direct and delayed type of injury
Structures
major vein 15-25%
major artery 10-15%
pharynx or esophagus 5-15%
larynx or trachea 4-12%
major nerves 3-8%

3. Type of Injury - Blunt Cervical spine Vascular injuries Aerodigestive
internal carotid artery
vertebral carotid artery
Aerodigestive
esophageal (rare)
larynx

4. Deadly Missed Neck Injuries
Carotid Artery Injury
Esophageal Perforation
Laryngotracheal Injury

5. Diagnosis Significant injuries often asymptomatic
25% positive symptoms and 25% positive signs
PE is often deceptively negative for severe injury
Symptoms variable and delayed
internal carotid artery > 2 weeks
esophageal
Weigelt (A J Surg 1987) 3/10 no signs or symptoms
laryngeal
more likely to have presenting symptoms/signs
voice change, SOB, hemoptysis

6. Keys to Diagnosis Little need for labs High index of suspicion
Sense of urgency
Operation vs radiology

7. Case #1 21 yom with GSW to right neck without exit site
c/o pain in throat/right neck
VS : HR 110, BP 130/70, RR 27 sats 98% (40%)
PE:
mild swelling right neck, non-pulsetile ??

8. Penetrating Neck Zones

9. Vascular Injuries - Physical Exam
Penetrating
Fogelman et al (Am J Surg,1956)
43% hemodynamically stable
70% no sign of bleeding
Carducci et al(Ann Emerg Med, 1985)
1/3 no signs/symptom
Apffelstaedt et al (World J Surg, 1994)
Prospective study, 335 patients
SW penetrating platysma
clinical signs absent 30% of positive neck explorations

10. Physical Exam - Penetrating
Reliable for significant vascular injuries
Demetriades et al (Br J Surg, 1993)
prospecitive 335 patients, detailed written protocol
7/335 required angiography
269/335 nonoperative managed
2 required subsequent operations for vascular injury
no complications
Demetriades et al (World J Surg, 1996)
prospective 223 patients, strict written protocol(Doppler)
160/223 no clinical signs underwent angio
no vascular injury requiring treatment

11. Overview Management Penetrating Neck
Zone I
routine angiography
? Esophageal evaluation (EGD, swallow)
Airway evaluation (bronchoscopy)
Zone II
selective management vs operative
neither approach superior (Asensio et al, Surg Clin N Amer, 1991)
Zone III

12. Angiography Recommended in Zone I and III
difficult to assess clinically
difficulty surgical exploration
Policy reduces nontherapeutic intervention
Costs (Demetriades et al, Br J Surg, 1993)
Zone I only 5% required operation
Zone III only 13% required operation

13. Zone III GSW

14. Zone III GSW

15. Management Penetrating Zone II
Mandatory exploration
Advantages
decreased injuries
up to 25% unexpected injuries found
low morbidity/mortality
Disadvantages
report up 67% negative exploration
Recommendations
Zone II injuries with/without instability
GSW that cross midline

16. Transcervical GSW More likely to involve vital structures
73% vs 31% (GSW not cross midline)
Hirshberg et al, Am J Surg 1994
retrospective 41 patients
30(83%) positive for cervical injury
recommends mandatory exploration
Demetriades et al, J of Trauma, 1997
prospective, 33 patients
73% injury to vital organ, only 21% therapeutic operation

17. Stab vs Gunshot Wounds Anecdotal suggestion
explore GSW, non-operative SW
not supported in literature
Prospective study (Demetriades et al, Br J Surg, 1993)
97 GSW, 89 SW
GSW higher incidence of clinical signs than knives (35% vs 19%)
GSW more likely injuries
therapeutic operation: GSW 16.5%, SW 10.1%

18. Zone II - “Selective Conservatism”
If hemodynamically stable
angiography, contrast study, endoscopy , +/- laryngoscopy
Exploration if positive study
Negative neck exploration 20%
Missed injuries negligible (Jurkovich et al, Trauma, 1985)
Disadvantages
cost and time
iatrogenic (CVA, esophageal perfs)

19. Acute Management Zone II Injury

20. Treatment- Specific Injuries
Carotid injuries
22% of penetrating cervical vascular injuries
mortality 10-20% (in-hospital)
Repair vs ligation
repair if possible in absence of neurologic deficits
prefer saphenous vein, but prosthetics ok
if internal carotid injuries, transposition of external carotid
ligation in neurologically intact for high internal carotid injury if very difficult or impossible

21. Treatment- Specific Injuries
Carotid injury
Presence of neurologic deficits
controversial
? Concern of postvascularization hemorrhagic infarct
increased risk if evidence of sever anemic infarct or edema
recommend repair
if deficits are short of coma
no evidence of anemic infarct
patent distal carotid

22. Treatment- Specific Injuries
Carotid artery occlusion with symptoms
may result in late local or neurologic complications
may develop pseudoaneurysm or rupture
recommend repair if
technically feasible
not at base of skull

23. Carotid Intimal Flap

24. Treatment - Specific Injuries
Minor carotid injuries (intimal flaps)
natural history not known
controversial: observation vs aggressive approach
? role of duplex for decision making
role of anti-platelet unproven, but used

25. Vertebral Artery Pseudoaneurysm

26. Management - Specific Injuries
Vertebral artery
increased frequency secondary liberal angio
10% of major vascular injuries
67% have association with major cervical injury mainly spine
isolate injury asymptomatic in 1/3 patients
thrombosis rarely lead to neurologic sequelae
angiographic embolization standard of care if bleeding

27. Complications Nonoperative Management Operative Management
delayed bleeding
CVA (dissection, emboli)
pseudoaneurysm
sepsis (missed esophageal leak)
Operative Management
injury to nerves (vagus, hypoglossal, recurrent)
blood loss
missed injury (particularly esophageal)

28. Summary Treatment - Vascular Injury
Surgical exploration unstable and stable Zone II (board answer)
Angiography Zone I and III
? Nonoperative management stable Zone II
depends on expertise and facilities
Other interventions
embolization high carotid or vertebral artery
endovascular stent (pseudoaneurysms)
anticoagulation blunt carotid/vertebral artery

29. Case #2 56 yom s/p MVC driver vs pole
Found unconscious at scene, intubated
VS: HR 90, BP 110/80, sat 100%
PE:
abrasions to left shoulder/mid chest/LUQ
GCS 7, pupil equal/reactive ??

30. Carotid Artery Dissection Internal Carotid Occlusion

31. Blunt Carotid Injury Low incidence (0.08-0.25%)
Male 76%, Mean age 35 +/- 2 yrs
Most commonly intimal disruption
? asymptomatic
Louisville U. (1998) 24 BCI all symptomatic
Colorado U. (1998) 12/56 asymptomatic
Often delayed diagnosis (Krajewski, Ann Surg 1980)
58% > 10hrs
36% > 24 hrs

32. Blunt Carotid Injury Eiology Associated injuries
MVC 41% (seat belt not a factor)
Fall/ped struck 14%
MCC 11%
other 22%
ski
bike
assault
near hanging
horseback
Associated injuries
CHI 65%
facial fx 60%
thoracic 51%
basilar skull fx 32%
extremity fx 32%
abdominal 30%
pelvic fx 16%
cervical fx 5%
none 16%
Biffl et al, Ann Surg, 1998

33. Diagnosis - Vascular Injury
Careful PE
hematomas, bruit, thrill
Horner’s syndrome
limb paresis or paralysis
deep coma
Delayed up to several days
PITFALL: Failure to consider blunt carotid injury with negative CT and CNS changes delayed

34. Blunt Carotid Injury Screening asymptomatic (Biffl et al, 1998)
severe neck hyperflexion, flexion, or rotation
significant soft-tissue injury anterior neck
cervical spine fracture
displaced midface fx or mandibular fx associated with a major injury mechanism
basilar skull fx involving sphenoid/mastoid/petrous/foramen lacerum

35. Blunt Carotid Injury Biffl et al, 1998 (continued)
before screening 12/12429 (0.1%)
after screening 25/2902 (0.86%)
only 28% had lateralizing signs/symptoms
25% had concomitant head injury/depressed MS
symptoms and timing
> 24 hrs - 28%
> 1 week %

36. Blunt Carotid Injury Biffl et al, 1998 (continued)
Outcome by symptoms at diagnosis
Dead Major Minor Normal
Asymptomatic
Symptomatic

37. Blunt Carotid Injury Biffl et al, 1998 Treatment Outcome
Operative =1/37
Anticoagulation = 24/37
endovascular stent 10/24
No intervention = 11/37
Outcome
Dead Major Minor Normal
Anticoagulation
No Anticoagulation

38. Blunt Carotid Injury Biffl et al, 1998 Complications Summary
angiography (2) - groin hematoma(1), CVA (1)
hemorrhagic
54% rebleeding ( transfusions and/or cessation)
Summary
Anticoagulation improves outcome
confirmed Fabian et al, Ann Surg, 1996
Aggressive screening ( ? Diagnostic test)
Optimal intervention ?
Stenting pseudoaneurysm

39. Blunt Carotid Injury Contraindicaton to Heparin No Yes Heparin Observe
Angiography 7-10 d Pseudoaneurysm
Yes No
Coumadin 3 mos
Heparin/Stent or OR

40. Vascular Injury - Radiologic Test
C- spine films
r/o fractures (spine/larynx)
? subcutaneous air
anterior cervical soft tissue swelling
tracheal deviation
? CXR/ skull xray (where’s the bullet ?)

41. BCI and Anticoagulation
Fabien et al, Surg, 1996

42. Vascular Injury - Radiologic Test
Duplex
can be used for carotid injuries Zone II only
as useful as angio in stable patients with Zone II injury (Thal, Trauma, 1991)
operator dependent
CT Angiogram
limited studies
? comparable to angiogram (missed blunt injuries)
advantage: no risk of CVA

43. Vascular Injury - Radiologic Test
Angiography
gold standard (4 vessel runoff)
Indications
proximity to carotid with or without hematoma
shotgun blasts with ? multiple artery segments injuries
precise localization for planning proximal or high carotid injury
blunt trauma with extensive soft-tissue injury
blunt trauma with neurologic loss unexplained by CT

44. Case #3 29 yof restrained driver, head-on MVC
reported striking face/neck on steering wheel c/o neck/throat pain
airway patent without voice change
PE:
anterior neck crepitus
no stridor ??

45. Diagnosis - Esophageal
Blunt esophageal injury rare
High index of suspicion in blunt trauma
Penetrating trauma - evaluation part of a complete work-up
If missed, high morbidity/mortality

46. GSW Anterior-Posterior Neck

47. Esophageal Injury - Diagnostic Test
Contrast swallow
Extravasation is diagnostic
Negative study is not reliable (particular in neck with gastrograffin)
50% of leaks missed with gastrograffin
25% of leaks missed with barium

48. Gastrograffin swallow

49. Esophageal Injury - Diagnostic Tests
Controversy of initial contrast to use
gastrograffin
pneumonitis if aspirated
barium
increased inflammation/infection in the mediastium
Rec: If gastrograffin study is negative, repeat swallow this barium. Avoid gastrograffin in patients without gag/cough

50. Esophageal Injury - Diagnostic Test
Endoscopy
Generally recommended when contrast swallow is negative, but suspicion is high
Perforations often readily seen, however
50% missed (Weigelt et al Am J Surg 1987)
missed in pharynx and cervical esophagus
missed in patients on ventilator (poor expansion of esophagus)
Combination of swallow/esophagoscopy reduces missed injuries to < 5%

51. Treatment - Esophageal Injury
Negative studies/high suspicion
24 hr observation
Pharyngeal
usually non-operative
NPO/IV Abx
Esophageal
resection
? diversion

52. Laryngotracheal Injury
Larynx extends from epiglottis opposite C3 to cricoid cartilages at level C6
Cervical trachea cricoid to thoracic inlet
Injury
penetrating
blunt

53. Penetrating Laryngotracheal Trauma
5-15% of penetrating neck trauma
larynx 33%
cervical trachea 67%
Doubled if esophagus injury
25% of airway injuries have esophageal injury

54. Blunt Laryngotracheal Injury
Most common cause is MVC
hitting steering wheel or dashboard
“clothesline” with ATV/snowmobile
Endotracheal intubation
arytenoid subluxtion
recurrent nerve paralysis (balloon overinflation)

55. Thyroid Fracture

56. Diagnosis - Laryngotracheal Injury
Pathology
subglottic/supraglottic submucosa edema/air
usually occurs within 6 hours
> 70% cross-sectional area reduced before symptoms
Associated with cervical spine injury
Voice change most common
Other S/S: dyspnea, pain, score throat, dysphagia, odynophagia, hemoptysis, subcutaneous air

57. Diagnosis - Laryngotracheal Injury
Plain xrays
soft tissue emphysema
airway compression
fracture of laryngeal cartilages
CT scan
detailed and accurate appraisal
Endoscopy
Flexible vs rigid
Bronchoscopy/laryngoscopy 100% accurate

58. Management of Laryngotracheal Injury
Airway control
Preparation for surgical airway
Non-operatively if,
clinically stable airway
endoscopy shows no displaced cartilages, mucosal disruptions or progressive edema/hematoma
therapy
semi-fowler position, humidified air, steroids, IV abx

59. Management of Laryngotracheal Injury
Operative
tracheostomy if airway unstable
no advantage in delay > 24 hrs to repair fx
laryngeal fractures
thyroid fx most common
reduction and fixation with stainless +steel sutures
delay of reduction > 7-10, scarring makes it more difficult and return of normal function unlikely

60. Outcomes of Laryngotracheal Injury
1/3 of patients who survive airway injury reach hospital alive suffer delay in diagnosis and treatment
preventable death in 10% in upper airway trauma (most secondary to delay)
most have some permanent voice and airway impairment or tendency to aspirate
problems most significant after blunt injury and penetrating (more extensive damage)

61. Errors in Management of Laryngeal Trauma
Assuming airway problem in unconscious patient is only due to prolapse of the tongue
attempting blind intubation in suspected larygneal injury
inserting ET tube with force is through vocal cords and fails to advance
use of muscle relaxation in a patient with a possible cricotracheal separation
Inadequate assessment of esophageal injury