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Penetrating and Blunt Neck Trauma Tintinalli Chapter 258

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... (neck trauma can lead to mediastinitis) Initial Management ABC s Always be ready for a cricothyroidotomy Maintain C Spine alignment until cleared via Nexus ... – PowerPoint PPT presentation

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Title: Penetrating and Blunt Neck Trauma Tintinalli Chapter 258


1
Penetrating and Blunt Neck TraumaTintinalli
Chapter 258
2
Anatomy
  • Complex network of neurovasuclar muscular
    structures supported by various fascial planes
  • Two methods used to describe the neck Zones
    Triangles
  • Anterior Triangle anteriorly by the midline
    posteriorly by the SCM superiorly by the
    mandible
  • Posterior Triangle anteriorly by the SCM
    inferiorly by the clavicle posteriorly by the
    anterior border of the trapezius muscle

3
Anatomy
  • Anterior Triangle Structures carotid artery,
    internal jugular vein, vagus nerve, thyroid
    gland, larynx, trachea, and esophagus
  • Posterior Triangle Structures few vital
    structures, except at its base, where the
    subclavian artery and brachial plexus are located

4
Anatomy
  • Zones
  • One superiorly from the sternal notch
    clavicles to the cricoid cartilage (injury
    affects both neck mediastinal structures)
  • Two cricoid cartilage to the angle of the
    mandible
  • Three angle of the mandible to the base of the
    skull

5
Anatomy
  • Zone I includes the vertebral and proximal
    carotid arteries, major thoracic vessels,
    superior mediastinum, lungs, esophagus, trachea,
    thoracic duct, and spinal cord
  • Zone II involve the carotid and vertebral
    arteries, jugular veins, esophagus, trachea,
    larynx, and spinal cord
  • Zone III includes the distal carotid and
    vertebral arteries, pharynx, and spinal cord

6
Anatomy
  • Fascial Planes
  • Platysma thin muscle covers the entire anterior
    triangle and the anteroinferior aspect of the
    posterior triangle serves as an important planar
    landmark when evaluating penetrating neck
    injuries
  • Deep Cervical Fascia invest deep structures
    important due to the pretracheal deep fascias
    communication to the anterior mediastinum (neck
    trauma can lead to mediastinitis)

7
Initial Management
  • ABCs
  • Always be ready for a cricothyroidotomy
  • Maintain C Spine alignment until cleared via
    Nexus (if you believe in it) or imaging or BOTH
  • Direct pressure for bleeding
  • Disability try to assess quickly if intubation

8
Signs and Symptoms
  • Hard (trauma more likely)
  • Hypotension in the ED
  • Active Arterial Bleeding
  • Diminished Carotid Pulse
  • Expanding Hematoma
  • Bruit
  • Lateralizing Signs
  • Hemothroax gt 1000 mL
  • Air Bubbling Wound
  • Hemoptysis
  • Hematemesis
  • Soft
  • Hypotension in the field
  • HX of Arterial bleeding
  • Tracheal deviation
  • Large hematoma
  • Stridor
  • Hoarseness
  • Vocal cord paralysis
  • Sub Q Air
  • 7th cranial nerve injury
  • Unexplained bradycardia

9
Diagnostic Strategies
  • Prospective study of 393 patients with
    penetrating neck injuries found 30 of patients
    with no physical findings had positive findings
    on surgical exploration.
  • Another study of 223 patients found physical
    examination was reliable to determine which
    patients needed vascular or esophageal studies.
  • However, if hard signs present, then evaluation
    should continue

10
Mechanism of Injury
  • Penetrating Injuries
  • Blunt Injuries
  • Strangulation

11
Penetrating Injury
  • Is the platysma penetrated?
  • Stable vs. Unstable
  • Stable
  • Zone I injures should undergo angiography and
    esophagram and/or esophagoscopy
  • Zone III injures should undergo angiography and
    thoracic consultation
  • Zone II undergo mandatory exploration or be
    evaluated with angiography and esophagram and/or
    esophagoscopy
  • Patients with laryngotracheal symptoms require
    laryngoscopy bronchoscopy
  • Helical CT Angiogram is an option for stable
    patients, but sensitivity not as good for zone I
    III injury patterns

12
Evaluation Plan
13
Blunt Injury
  • Much more rare
  • Symptoms may be minimal or delayed
  • Classic symptoms include dysphonia, hoarseness,
    dysphagia, odynophagia, dyspnea, pain,
    hemoptysis, and stridor
  • Laryngoscopy and bronchoscopy - vocal cord
    function, luminal integrity, and level of injury
  • Esophagram esophagoscopy if significant injury
    found to other structures or high clinical
    suspicion
  • Causes 3-10 of all cervical vascular injury
  • Two patterns - pseudo-aneurysm or dissection can
    occur (new bruit or neurologic symptoms)

14
Strangulation
  • Severe Hoarseness stridor are suggestive of
    impending airway obstruction
  • Death from three Mechanisms
  • Injury to the spinal cord or brain stem
  • Mechanical constriction of the neck structures
  • Cardiac Arrest

15
Strangulation Treatment
  • C spine injury is rare unless significant drop
    during strangulation
  • Neurogenic pulmonary edema best prevented with
    PEEP
  • Cardiac monitoring essential to follow possible
    dysrhythmias
  • Watch for increased ICP (Cushings)

16
Pearls
  • Exsanguination is the leading cause of immediate
    death
  • Esophageal injury is the leading cause of delayed
    death
  • Neck wounds should never be probed can lead to
    massive hemorrhage or air embolus
  • Cervical Collars can obscure significant injury
  • Vascular injury from blunt trauma is difficult to
    identify
  • Transcervical gunshot wounds have a high
    incidence of visceral-vascular injury
  • All near-hanging or strangulation patients who
    are comatose or AMS may have elevated ICP

17
Reference
  • Tintinalli Chapter 258
  • Rosens Chapter 41
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