Penetrating Neck Trauma: Anatomy, History, Zones, and Ballistics, Slides of General Surgery

Download Penetrating Neck Trauma: Anatomy, History, Zones, and Ballistics and more Slides General Surgery in PDF only on Docsity! Penetrating Neck Trauma Docsity.com Introduction • 5-10% of all trauma • Overall mortality rate as high as 11% • Major vessel injury fatal in 65%, including prehospital deaths • Attending physician must have excellent knowledge of anatomy • Multidisciplinary Docsity.com Zone I • Bound superiorly by the cricoid and inferiorly by the sternum and clavicles • Contains the subclavian arteries and veins, the dome of the pleura, esophagus, great vessels of the neck, recurrent nerve, trachea • Signs of significant injury may be hidden from inspection in the mediastinum or chest Docsity.com Zone II • Bound inferiorly by the cricoid and superiorly by the angle of the mandible • Contains the larynx, pharynx, base of tongue, carotid artery and jugular vein, phrenic, vagus, and hypoglossal nerves • Injuries here are seldom occult • Common site of carotid injury Docsity.com Zone III • Lies above the angle of the mandible • Contains the internal and external carotid arteries, the vertebral artery, and several cranial nerves • Vascular and cranial nerve injuries common Docsity.com Ballistics • Injuries inflicted with high power rifles, shotguns at less than 20 feet, and .357 and .45 caliber handguns can cause extensive damage extending beyond the path of the projectile and should be explored Docsity.com Ballistics • Stab wounds do not have this effect • Beware of the stab wound just over the clavicle -- the subclavian vein is at high risk Docsity.com Airway • Established Airway – be prepared to obtain an airway emergently – intubation or cricothyrotomy – beware of cutting the neck in the region of the hematoma -- disruption there of may lead to massive bleeding – must assume cervical spine injury until proven otherwise Docsity.com Obtain History • Obtain from EMS witnesses, patient • Mechanisms of injury - stab wounds, gunshot wound, high-energy, low-energy, trajectory of stab • Estimate of blood loss at scene • Any associated thoracic, abdominal, extremity injuries • Neurologic history Docsity.com Physical Examination • Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits • Neuro exam: mental status, cranial nerves, and spinal column • Examine the chest, abdomen, and extremities • Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here • Don’t blindly explore wound or clamp vessel Docsity.com Xrays • CXR - inspiratory/expiratory films to assess for phrenic nerve injury, look for pneumothorax • Cervical spine film to rule out fractures • Soft tissue neck films AP and Lateral • Arteriograms, contrast studies as indicated • CT scan still not standard of care yet Docsity.com Exploration or Observation • Some experts have adopted a policy of selective exploration • Decreased number of negative explorations, increased number of positive explorations • Decreased cost of medical care, maybe • No increase in mortality when adjunctive diagnostic studies and serial exams performed • Patients taken to OR if clinical exam changes, around 2% in most studies Docsity.com Zone I • Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy • High morbidity of exploration, thus suspicion must be great before taking the patient to OR • Cardiothoracic surgery consultation a must • Angiography is essential Docsity.com Zone II • Few injuries will escape clinical examination • Most carotid injuries occur here • Adjunctive studies, except barium swallow and esophagoscopy where indicated, are not necessary • Asymptomatic zone II injuries can generally be safely managed by observation Docsity.com Pharyngo Esophageal • High mortality for missed injuries, delayed diagnosis >12h • Contrast swallow studies • Flexible ± rigid esophagoscopy • Invert the mucosal edges and close with two layers of absorable sutures • JP drain and muscle flap, especially if concomitant vascular repair. Docsity.com Airway • DL where laryngeal injury is suspected • Mucosal tears are closed with absorbable sutures • Tracheotomy one ring below injury when high tracheal injury • May need graft if more than two rings gone Docsity.com Vascular • The subclavian and internal jugular veins can be ligated without adverse effect • Major arteries should be repaired where possible except the vertebral which can be ligated or embolized • Partial lacerations can be closed primarily -- vein patches will help prevent subsequent stenosis • High velocity wounds produce a surrounding area of contusion which may be thrombogenic and which must be resected; then primary reanastamosis if possible Docsity.com