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Health-Process Evidence-Based Clinical Practice Guidelines for Neck Trauma

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Title: Health-Process Evidence-Based Clinical Practice Guidelines for Neck Trauma


1
Health-ProcessEvidence-BasedClinical Practice
Guidelinesfor Neck Trauma
  • Jonathan Malabanan MD
  • OMMC
  • February 21, 2007

2
Neck Trauma
  • A. Overview of the Problem
  • Concept
  • Common Types
  • Common Causes
  • B. General Management Guidelines
  • Clinical Diagnosis
  • Para clinical Diagnosis
  • Treatment

3
Clinical Questions
  • What is an operational concept of neck trauma?
  • Trauma - body injury produced by
  • sudden force
  • Neck - region of the body above the clavicle
    up to the occiput line

4
Clinical Questions
  • What is the operational concept of Non-
    Penetrating Neck Injury?
  • - The object does not traverse the platysma.

5
Clinical Questions
  • What is the operational concept of Penetrating
    Neck Injury?
  • - The object traverses the platysma.

6
Clinical Questions
  • How is neck trauma classified in terms of
    mechanism of injury?
  • Blunt/ non- penetrating neck injury
  • Penetrating neck injury

7
Clinical Questions
  • 5. What are the most common causes of penetrating
    neck injury?
  • Assault with sharp object such as stab wound etc.
  • Gunshot Injury

8
Clinical Questions
  • 6. What are the hard signs and symptoms that will
    indicate that a patient had penetrating neck
    injury?
  • Hemodynamic ally unstable
  • Expanding hematoma
  • Dispend
  • Brisk bleeding
  • Thrill/Bruit
  • Uselessness

9
Clinical Questions
  • What are the soft signs and symptoms that will
    indicate that a patient had penetrating neck
    injury?
  • Hemoptysis
  • Hematemesis
  • Subcutaneous emphysema
  • Small, non-expanding hematoma
  • Hoarseness
  • Neurologic deficits

10
PENETRATING TRAUMA
HEMODYNAMICALLY UNSTABLE PX OR HEMODYNAMICALLY ST
ABLE WITH HARD SIGNS
HEMODYNAMICALLY STABLE PX
WITH SOFT SIGN
ASYMPTOMATIC
EXPLORE
DIAGNOSTICS
OBSERVE
POSITIVE
NEGATIVE
EXPLORE
OBSERVE
11
8. If a paraclinical diagnostic procedure is
needed for trauma to the neck area, the most
cost effective would be
BENEFIT RISK COST AVAILABILITY
Angiography Injury to ICA vertebral artery can be controlled by embolization Easier to perform neck exploration for zones I III vascular injury Exposure to radiation invasive P15,000.00 Not available
Tracheobroncoscopy - Direct visualization of trachea and larynx -added trauma P5,000.00 Available
Rigid Esophagoscopy -Direct visualization of esophagus -added trauma P5,000.00 Available
Esophagogram -good only for intraluminal structures -invasive small injuries are hard to detect P8,000.00 Available
12
GOALS OF TREATMENT
  • Neck Exploration
  • Control of hemorrhage
  • Identification and repair of injured part

13
8. What is the operative treatment for
penetrating neck injury in unstable patients?
  • Mandatory Neck Exploration

14
Treatment Options for vascular injury
Benefit Risk Cost Availability
Ligation Easier to Perform. Lesser time is utilized. Safer to perform Lower Risk of Rebleeding Edema P5000 available
Repair More difficult to perform. Utilize more time. Higher Risk of Rebleeding Swelling P5000 available
15
Practice Level of Evidence
  • Standards (I) need to be followed
  • Guidelines (II) suggested
  • Options (III) considered

16
RecommendationsA. Selective Workup Operation
vs. Non- Operative Management
  • Level 1 Selective operative management and
    mandatory exploration of penetrating injuries to
    Zone II of the neck are equally justified and
    safe.
  • Level 2 No recommendation.
  • Level 3 No recommendation.

17
RecommendationsB. Diagnosis of Arterial Injury
  • Level 1 No recommendation
  • Level 2 CT angiography or duplex ultrasonography
    can be used in lieu of arteriography to rule out
    an arterial injury in penetrating injury to Zone
    II of the neck.

18
RecommendationsB. Diagnosis of Arterial Injury
  • Level 3 CT of the neck (even without CT
    angiography) can be used to rule out a
    significant vascular injury if it demonstrates
    that the trajectory of the penetrating object is
    remote from vital structures. With injuries in
    proximity to vascular structures, minor vascular
    injuries such as intimal flaps may be missed.

19
RecommendationsC. Diagnosis of Esophageal
Injury
  • Level 1 No recommendation
  • Level 2 Either contrast esophagography or
    esophagoscopy can be used to rule out an
    esophageal perforation that requires operative
    repair. Diagnostic workup should be expeditious
    because morbidity increases if repair is delayed
    by more than 24 hours.

20
RecommendationsC. Diagnosis of Esophageal
Injury
  • Level 3 No recommendation.

21
RecommendationsD. Value of Physical Exam
  • Level 1 No recommendation.
  • Level 2 No recommendation.
  • Level 3
  • 1.) Careful physical examination, including
    auscultation of the carotid arteries, is gt95
    sensitive for detecting arterial injuries that
    require repair.

22
RecommendationsD. Value of Physical Exam
  • Level 3 Given the potential morbidity of missed
    injuries imaging is still recommended.
  • 2.) Physical examination is inadequate to rule
    out injuries to the aero digestive tract.

23
RecommendationsE. Management of Specific
Vascular Injuries
  • Level 1 No recommendation.
  • Level 2
  • 1. Except for minimal intimal irregularities or
    small pseudo aneurysms without neurologic
    deficits, penetrating injuries to the internal
    carotid artery should be repaired, even when
    severe neurologic deficits are present.

24
RecommendationsE. Management of Specific
Vascular Injuries
  • Level 2
  • 2. Angiographic approaches to the vertebral
    artery are preferred to operative approaches for
    patients with bleeding from vertebral artery
    injuries.
  • 3. Ligation of the jugular vein is
    appropriate for complex injuries or unstable
    patients.

25
RecommendationsE. Management of Specific
Vascular Injuries
  • Level 3 No recommendation.

26
RecommendationsF. Cervical Spine
Immobilization
  • Level 1 No recommendation.
  • Level 2 Immobilization of the cervical spine is
    unnecessary unless there is overt neurologic
    deficit or an adequate physical examination can
    not be performed, e.g., the unconscious victim.
  • Level 3 No recommendation.

27
Resolution
  • Selective management of penetrating injuries to
    Zone II of the neck has become common for
    asymptomatic patients.
  • The roles of physical examination, arteriography,
    duplex US, CT angiography, esophagography, and
    esophogoscopy remain unclear.

28
Resolution
  • At the moment, the single imaging modality that
    holds the greatest potential for ruling out
    vascular, tracheal, and esophageal injuries is CT
    angiography.

29
References
  • Schwartz et. al Principles of Surgery.8th ed.
    Chapter 6.
  • Nason et.al Penetrating Neck Injuries Analysis
    of Experience from Canadian Trauma Centre.
    Journal Canadian de Chirurgie. Vol. 24, 2001.
  • Tisherman et.al Clinical Practice Guideline
    Penetrating Neck Trauma. Eastern Association for
    Surgery of Trauma.

30
  • Thank you!
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