Title: Management of Penetrating Neck Trauma
1Management of Penetrating Neck Trauma
2MVA, aphasia, R hemiplegia
3Types of Weapons
- Low velocity knives, ice picks, glass
- High velocity handguns, shotguns, shrapnel
K1/2mv2
4Guns
lt
5Ballistics
6Anatomy
7Anatomy
Zone III
Zone II
Zone I
8Incidence and Mortality
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10Signs of Injury
Shock, Profuse bleeding, Evolving
stroke, Expanding hematoma, hemoptysis,
hematemesis, unequal pulses, bruits or thrills
Vascular
11Signs of Injury
Subcutaneous emphysema, Hoarseness, Respiratory
distress, Stridor
Larynx/Trachea
Neck pain, Blood in saliva, Fever, Odynophagia
Esophagus
12Initial Management
Airway
Intubation vs. Surgical Airway
Breathing
Circulation
IV access, Immediate Exploration
Examination
Determine weapon trajectory
13Management of the Stable Patient
The Standard
Wound Penetrates Platysma?
No
Yes
Immediate Neck Exploration
Observation/Discharge
Laryngoscopy Esophagoscopy
14The Standard
- Based on wartime experiences
- Fogelman et al (1956)
- immediate neck exploration-gt better outcomes in
vascular injuries. - negative neck explorations in gt 50
- Arteriogram?
- screening tool before exploration
- zone 1 and 3 injuries
- hard to detect on physical
- Safe answer on board exam
15Arteriogram
- Flint et al (1973)
- negative P.E. in 32 of pts. with major zone 1
vascular injury. - Arteriogram can be accompanied by treatment (e.g.
embolization).
16A Newer Algorithm
Mansour et al 1991 retrospective study
17Newer Algorithm (Mansour)
- 63 of the study population was in the
observation group. - Overall mortality 1.5
- similar to those in more rigorous treatment
protocols. - Similar results obtained in other large studies
with similar protocols (e.g. Biffi et al 1997). - NOTE Arteriogram in asymptomatic patients with
zone 1 injury.
18Points of Controversy
- Most trauma surgeons accept observation of select
patients similar to the Mansour algorithm. - Study by Eddy et al
- questions the necessity for arteriogram /
esophagoscopy in asymptomatic zone 1 injury (use
of P.E. and CXR resulted in no false negatives). - Other noninvasive modalities than arteriogram
exist for screening patients for vascular injury.
19CT scan
- Can id weapon trajectory and structures
- only in stable patients.
- Gracias et al (2001)
- CT scan in stable patients
- able to save patients from arteriogram indicated
by other protocols 50 of the time - avoid esophagoscopy in 90 of tested patients who
might otherwise have undergone it.
20Duplex Ultrasonography
- Requires the presence of reliable technician and
radiologist. - A double blinded study by Ginsburg et al (1996)
showed 100 true negative, 100 sensitivity in
detecting arterial injury, using arteriography as
the gold standard.
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23Is this really wise??
24Incision for Neck Exploration
25Incisions for Neck Exploration
26Management of Vascular Injuries
- Common carotid
- repair preferred over ligation in almost all
cases. - Saphenous vein graft may be used.
- Shunting is rarely necessary.
- Thrombectomy may be necessary.
- Internal carotid
- Shunting is usually necessary
- Vertebral
- Angiographic embolization
- proximal ligation can be used if the
contralateral vertebral artery is intact. - Internal Jugular Repair vs. ligation.
27Esophageal Injury
- Diagnosis
- esophagoscopy and esophagram in symptomatic
patients. - Injection of air or methylene blue in the mouth
may aid in localizing injuries. - Controlled fistula with T-tube
- exteriorization of low non-repairable wounds
- Small pharyngeal lesions above arytenoids can be
treated with NPO and observation 5-7 days - All patients should be NPO for 5-7 days.
28Laryngeal/Tracheal Injury
- Thorough Direct Laryngoscopy for suspicious
wounds - Tracheotomy for suspected laryngeal injury
29Thoracic Trauma
30Thoracic Trauma
- 2nd leading cause of trauma deaths
- after head injury
- 10-20 of all trauma deaths
- Many deaths are preventable
31Thoracic Trauma
- Mechanisms of Injury
- Blunt Injury
- Deceleration
- Compression
- Penetrating Injury
- Combination
32Thoracic Trauma
- Anatomical Injuries
- Thoracic Cage (Skeletal)
- Cardiovascular
- Pleural and Pulmonary
- Mediastinal
- Diaphragmatic
- Esophageal
- Penetrating Cardiac
33Thoracic Trauma
- Hypoxia
- hypovolemia
- pulmonary V/P mismatch
- ? in intrathoracic pressure relationships
- Hypercarbia
- ? in intrathoracic pressure relationships
- ? level of consciousness
- Impairments to cardiac output
- blood loss
- increased intrapleural pressures
- blood in pericardial sac
- myocardial valve damage
- Acidosis final result
- hypoperfusion of tissues
34Thoracic Trauma
- Initial exam directed toward life threatening
- Injuries
- Open pneumothorax
- Flail chest
- Tension pneumothorax
- Massive hemothorax
- Cardiac tamponade
35Thoracic Trauma
- Assessment Findings
- Mental Status
- decreased
- Pulse
- absent, tachy or brady
- BP
- narrow PP, hyper- or hypotension, pulsus
paradoxus - Ventilatory rate effort
- tachy- or bradypnea, labored, retractions
- Skin
- diaphoresis, pallor, cyanosis, open injury,
ecchymosis
36Thoracic Trauma
- Assessment Findings
- Neck
- tracheal position, SQ emph, JVD, open injury
- Chest
- contusions, tenderness, asymmetry, abN a/e, bowel
sounds, abnormal percussion, open injury, impaled
object, crepitus, hemoptysis - Heart Sounds
- muffled, distant, regurgitant murmur
- Upper abdomen
- contusion, open injury
37Thoracic Trauma
- Assessment Findings
- ECG (ST segment abnormalities, dysrhythmias)
- History
- Dyspnea
- Pain
- Past hx of cardiorespiratory disease
- Restraint devices used
- Item/Weapon involved in injury
38Thoracic Trauma
39Rib Fracture
- MC chest wall injury from direct trauma
- More common in adults than children
- Especially common in elderly
- Most commonly 5th - 9th ribs
- Poor protection
40Rib Fracture
- Fractures of 1st and 2nd second require high
force - Frequently have injury to aorta or bronchi
- Occur in 90 of patients with tracheo-bronchial
rupture - May injure subclavian artery/vein
- 30 will die
41Rib Fracture
- Fractures of 10 to 12th ribs can cause damage to
underlying abdominal solid organs - Liver
- Spleen
- Kidneys
42Rib Fracture
- Management
- PPV
- Analgesics for isolated trauma
- Non-circumferential splinting
- Monitor elderly and COPD patients closely
- Broken ribs can cause decompensation
- Patients will fail to breathe deeply and cough,
resulting in poor clearance of secretions
43Sternal Fracture
- Uncommon, 5-8 in blunt chest trauma
- Large traumatic force
- Direct blow to front of chest by
- Deceleration
- steering wheel
- dashboard
- Other object
44Sternal Fracture
- 25 - 45 mortality due to associated trauma
- Disruption of thoracic aorta
- Tracheal or bronchial tear
- Diaphragm rupture
- Flail chest
- Myocardial trauma
- High incidence of
- myocardial contusion, cardiac tamponade or
pulmonary contusion
45Sternal Fracture
- Management
- Establish airway
- High concentration oxygen
- Assist ventilations as needed
- IV NS/LR
- Restrict fluids
- Rule out associated injuries
46Flail Chest
- Usually secondary to blunt trauma
- Most commonly in MVA
- Also results from
- falls from heights
- industrial accidents
- assault
- birth trauma
- More common in older patients
47Flail Chest
- Mortality rates 20-40 due to associated injuries
- Mortality increased with
- advanced age
- seven or more rib fractures
- three or more associated injuries
- shock
- head injuries
48Flail Chest
- Consequences of flail chest
- Respiratory failure due to
- pulmonary contusion
- inadequate diaphragm movement
- Paradoxical movement of the chest
- must be large to compromise ventilation
- Increased work of breathing
- decreased chest expansion
- pain
49Flail Chest
- Suspect spinal injuries
- Establish airway
- Assist ventilation
- Treat hypoxia from underlying contusion
- Promote full lung expansion
- Consider need for intubation and PEEP
- Mechanically stabilize chest wall
- questionable value
50Flail Chest
- Management
- IV of LR/NS
- Avoid rapid replacement in hemodynamically stable
patient - Contused lung cannot handle fluid load
- Monitor EKG
- Chest trauma can cause dysrhythmias
51Simple Pneumothorax
- Incidence
- 10-30 in blunt chest trauma
- almost 100 with penetrating chest trauma
- Morbidity Mortality dependent on
- extent of atelectasis
- associated injuries
52Simple Pneumothorax
- a rib lacerates lung
- Usually well-tolerated in the young healthy
- Severe compromise can occur in the elderly or
patients with pulmonary disease - Degree of distress depends on amount and speed of
collapse
53Simple Pneumothorax
- HDI and respiratory distress
- High index of suspicion
- Chest tube when in doubt before CXR
54Open Pneumothorax
- If the trauma patient does not ventilate well
with an open airway, look for a hole - May be subtle
- Abrasion with deep punctures
- Opening in the chest wall
- Sucking sound on inhalation
- HDI/resp distress
- SQ Emphysema
55Open Pneumothorax
- Profound hypoventilation may occur
- communication between pleural space and
atmosphere - Prevents development of negative intrapleural
pressure - Results in ipsilateral lung collapse
- inability to ventilate affected lung
56Open Pneumothorax
- V/Q Mismatch
- shunting
- hypoventilation
- hypoxia
- large functional dead space
- Pressure may build within pleural space
- Return from Vena cava may be impaired
57Open Pneumothorax
- Cover chest opening with occlusive dressing
- Assist with positive pressure ventilations prn
- Monitor for progression to tension pneumothorax
58Tension Pneumothorax
- Incidence
- Penetrating Trauma
- Blunt Trauma
- Morbidity/Mortality
- Severe hypoventilation
- Immediate life-threat if not managed early
59Tension Pneumothorax
- Pathophysiology
- One-way valve forms in lung or chest wall
- Air enters pleural space, but cannot leave
- Pressure collapses lung on affected side
- Mediastinal shift to contralateral side
- Reduction in cardiac output
- Increased intrathoracic pressure
- deformed vena cava reducing preload
60Tension Pneumothorax
- Severe dyspnea ? extreme resp distress
- Restlessness, anxiety, agitation
- Decreased/absent breath sounds
- Worsening or Severe Shock
- Cardiovascular collapse
- Tachycardia
- Weak pulse
- Hypotension
- Narrow pulse pressure
61Tension Pneumothorax
- Jugular Vein Distension
- absent if also hypovolemic
- Hyperresonance to percussion
- Subcutaneous emphysema
- Late
- Tracheal shift away from injured side
- Cyanosis
62Tension Pneumothorax
- Recognize Manage early
- Establish airway
- Needle thoracostomy then chest tube
63Tension Pneumothorax
- Decompress with 14g (lg bore), 2-inch needle
- Midclavicular line 2nd intercostal space
- Midaxillary line 4-5th intercostal space
- Go over superior margin of rib to avoid blood
vessels - Be careful not to kink or bend needle or catheter
- If available, attach a one-way valve
64Hemothorax
- Most common result of major trauma to the chest
wall - Present in 70 - 80 of penetrating and major
non-penetrating trauma cases - Associated with pneumothorax
- Rib fractures are frequent cause
65Hemothorax
- Each can hold up to 3000 cc of blood
- Life-threatening often requiring chest tube
and/or surgery - If assoc. with great vessel or cardiac injury
- 50 die immediately
- 25 live five to ten minutes
- 25 may live 30 minutes or longer
- Blood loss results in
- Hypovolemia
- Decreased ventilation of affected lung
66Hemothorax
- Accumulation of blood in pleural space
- penetrating or blunt lung injury
- chest wall vessels
- intercostal vessels
- myocardium
- Massive hemothorax indicates great vessel or
cardiac injury - Intercostal artery can bleed 50 cc/min
67Hemothorax
- Chest tube, go to OR if
- 1000 cc out on insertion
- 200 cc/h for 4 hours
68Pulmonary Contusion
- Pathophysiology
- Blunt trauma to the chest
- Rapid deceleration forces cause lung to strike
chest wall - high energy shock wave from explosion
- high velocity missile wound
- low velocity as with ice pick
- Most common injury from blunt thoracic trauma
- 30-75 of blunt trauma
- mortality 14-20
69Pulmonary Contusion
- Pathophysiology
- Rib Fx in many but not all cases
- Alveolar rupture with hemorrhage and edema
- increased capillary membrane permeability
- Large vascular shunts develop
- Gas exchange disturbances
- Hypoxemia
- Hypercarbia
70Pulmonary Contusion
- Assessment Findings
- Evidence of blunt chest trauma
- Cough and/or Hemoptysis
- Apprehension
- Cyanosis
- CXR changes late
71Pulmonary Contusion
- Management
- Supportive therapy
- Early use of positive pressure ventilation
reduces ventilator therapy duration - Avoid aggressive crystalloid infusion
- Severe cases may require ventilator therapy
72Myocardial Contusion
- Most common blunt injury to heart
- Usually due to steering wheel
- Significant cause of morbidity and mortality in
the blunt trauma patient
73Myocardial Contusion
- Pathophysiology
- Behaves like acute MI
- Hemorrhage with edema
- Cellular injury
- vascular damage may occur
- Hemopericardium may occur from lacerated
epicardium - May produce arrhythmias
- hypotension unresponsive to fluid or drug therapy
74Myocardial Contusion
- Cardiac arrhythmias following blunt chest trauma
- Angina-like pain unresponsive to nitroglycerin
- Precordial discomfort independent of respiratory
movement - Pericardial friction rub (late)
75Myocardial Contusion
- ECG Changes
- Persistent tachycardia
- ST elevation, T wave inversion
- RBBB
- Atrial flutter, Atrial fibrillation
- PVCs
- PACs
76Myocardial Contusion
- IV LR/NS
- Cautious fluid administration due to injured
myocardium - ECG
- Standard drug therapy for arrhythmias
- 12 Lead ECG if time permits
- Admit to monitored evironment
77Pericardial Tamponade
- Incidence
- Usually associated with penetrating trauma
- Rare in blunt trauma
- Occurs in lt 2 of chest trauma
- GSW wounds have higher mortality than stab wounds
- Lower mortality rate if isolated tamponade
78- Tamponade is hard to diagnose
- Hypotension is common in chest trauma
- Heart sounds are difficult to hear
- Bulging neck veins may be absent if hypovolemia
is present - High index of suspicion is required
79Pericardial Tamponade
- Pathophysiology
- Space normally filled with 30-50 ml of
straw-colored fluid - lubrication
- lymphatic discharge
- immunologic protection for the heart
- Rapid accumulation of blood in the inelastic
pericardium
80Pericardial Tamponade
- Pathophysiology
- Heart is compressed decreasing blood entering
heart - Decreased diastolic expansion and filling
- Hindered venous return (preload)
- Myocardial perfusion decreased due to
- pressure effects on walls of heart
- decreased diastolic pressures
- Removal of as little as 20 ml of blood may
drastically improve cardiac output
81Pericardial Tamponade
- Becks Triad
- Resistant hypotension
- Increased central venous pressure
- distended neck/arm veins in presence of decreased
arterial BP - Small quiet heart
- decreased heart sounds
82Pericardial Tamponade
- Signs and Symptoms
- Narrowing pulse pressure
- Pulsus paradoxicus
- Radial pulse becomes weak or disappears when
patient inhales - Increased intrathoracic pressure on inhalation
causes blood to be trapped in lungs temporarily
83Pericardial Tamponade
- Management
- ECHO if stable to diagnose
- In ER
- consider pericardiocentesis
- Pericardial window followed by sternotomy in OR
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86Traumatic Aortic Dissection/Rupture
- Caused By
- Motor Vehicle Collisions
- Falls from heights
- Crushing chest trauma
- Animal Kicks
- Blunt chest trauma
- 15 of all blunt trauma deaths
87Traumatic Aortic Dissection/Rupture
- 1 of 6 persons dying in MVCs has aortic rupture
- 85 die instantaneously
- 10-15 survive to hospital
- 1/3 die within six hours
- 1/3 die within 24 hours
- 1/3 survive 3 days or longer
- Must have high index of suspicion
88Traumatic Aortic Dissection/Rupture
- Separation of the aortic intima and media
- Tear 2 high speed deceleration at points of
relative fixation - Blood enters media through a small intima tear
- Thinned layer may rupture
- Descending aorta at the isthmus distal to left
subclavian artery most common site of rupture - ligamentum arteriosom
89Traumatic Aortic Dissection/Rupture
- Assessment Findings
- Retrosternal or interscapular pain
- Pain in lower back or one leg
- Respiratory distress
- Asymmetrical arm BPs
- Upper extremity hypertension with
- Decreased femoral pulses, OR
- Absent femoral pulses
- Dysphagia
90CXR
91Work up
- CTA
- Angio is rarely used
- Address other injuries first
- Ideally, repaire when stable
- Stent vs open
92Diaphragmatic Penetration
- Suspect intra-abdominal trauma with any injury
below 4th ICS - Suspect intrathoracic trauma with any abdominal
injury above umbilicus
93Diaphragmatic Rupture
- Usually due to blunt trauma but may occur with
penetrating trauma - Usually life-threatening
- Likely to be associated with other severe injuries
94Diaphragmatic Rupture
- Pathophysiology
- Compression to abdomen resulting in increased
intra-abdominal pressure - abdominal contents rupture through diaphragm into
chest - bowel obstruction and strangulation
- restriction of lung expansion
- mediastinal shift
- 90 occur on left side due to protection of right
side by liver
95Diaphragmatic Rupture
- Assessment Findings
- Decreased breath sounds
- Usually unilateral
- Dullness to percussion
- Dyspnea or Respiratory Distress
- Scaphoid Abdomen
- Usually impossible to hear bowel sounds
- Management
- suspect
- NG tube
- CT
- Laparoscopy
- Sensitive and specific
96Esophageal Injury
- Penetrating Injury most frequent cause
- Rare in blunt trauma
- Can perforate spontaneously
- violent emesis
- carcinoma
97Esophageal Injury
- Assessment Findings
- Pain, local tenderness
- Hoarseness, Dysphagia, Respiratory distress
- Mediastinal esophageal perforation
- mediastinal emphysema / mediastinal crunch
- SQ Emphysema
- Shock
- Abx
- resuscitation
- Early diagnosis
- Gastrographin -gt dilute Ba
- Repair vs exclude
98Tracheobronchial Rupture
- Uncommon injury
- less than 3 of chest trauma
- Occurs with penetrating or blunt chest trauma
- High mortality rate (gt30)
- Respiratory Distress
- Obvious SQ emphysema
- Hemoptysis
- Especially of bright red blood
- Signs of tension pneumothorax unresponsive to
needle decompression
99Tracheobronchial Rupture
- Majority (80) occur at or near carina
- rapid movement of air into pleural space
- Tension pneumothorax refractory to needle
decompression - Consider early intubation
- intubating right or left mainstem may be life
saving - If arrest and suspect air embolysm, may have to
do ERT
100Damage control
101Damage control principle
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105ED Thoractomy
- Thoracotomy performed in ER
- for resuscitation of patients arriving in
extremis - Plan to take to OR afterwards
- AIM
- Expeditious control of hemorrhage
- Maximization of coronary and cerebral perfusion
- Release of pericardial tamponade
- Tx of massive air-embolysm
106Procedure Left Anterolateral Thoracotomy
107Clamshell Thoracotomy
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109Release Pericardial Tamponade
110Control Intrathoracic Hemorrhage
111Eliminate massive air embolism or bronchopleural
fistula
- Post intubation positive pressure ventilation
- Get air transfer across traumatic alveolovenous
channels - Pulmonary hilar cross clamping
- Air aspirated from L ventricular apex and aortic
root - Cardiac massage
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113Perform Open Cardiac Massage
- Bimanual internal massage with hands in a hinged
clapping motion - Ventricular compression proceeding from apex to
base of heart
114Occlude Descending Thoracic Aorta
115Futile?
- Overall survival 4-5
- Little to Lose
- risk to Health care workers
- Risk blood contact
- 26 trauma pts HIV or Hepatitis
- Health care costs
- J Trauma. 1998 Jul45(1)87-94
116Selective Application of ED Thoracotomy
- Mechanism of Injury
- Presence of Vital Signs
- Location of Injury
- Other Signs of Life
117Survival based on mechanism
J Trauma. 1998 Jul45(1)87-94
118Presence of vital signs
J Trauma. 1998 Jul45(1)87-94
119Survival based on organ injured
JACS 2000 Mar190(3)288-98.
120Other Signs of Life (SOL)
JACS 2000 Mar190(3)288-98.
121What about PEA?
26/62 (42) ED Thoracotomy survivors had PEA
requiring CPR
JACS 199211-215, 2004
122Conclusions
- ER thoracotomy considered in pts w/
- Presence of vital signs in field or hospital
- Better results in penetrating cardiac injury
- Results w/ Blunt trauma poor, but survivors exist
- PEA after penetrating trauma from stabs
- Up to 70 good outcomes
- Contraindicated in pts with
- No vital signs, prolonged asystole and
unwitnessed arrest/loss of SOL - JACS 199211-215, 2004
123Finally
- PEA after blunt trauma?
- Typically poor outcome, but occasionally will
have a survivor - If CPR gt 5 min, contraindicated
124References and thanks
- Thank God for internet and Google
- several websites specifically
- http//www.adhb.govt.nz/trauma/presentations/Forum
s/major20chest20injuries/sld001.htm - http//www.templejc.edu/dept/ems/Pages/PowerPoint.
html - http//www.mssurg.net
- www.nordictraumarad.com/Syllabus06/mo2015/NORDTER
penetrating.pdf - www.iformix.com/spu/chest_trauma.ppt
- Greenfield textbook of surgery