3. Presentation to Lithgow 19M, riding motorcycle in the bush- helmet, no leathers Felt sudden sharp severe pain in R anterolateral neck Brought by friends to Lithgow Hospital Entry wound over anterolateral R SCM near angle of mandible, neck swelling CT neck Lightgow -metallic FB 9mm R neck, parapharyngeal haematoma with tracheal deviation Therefore arranged for urgent transfer to Trauma Centre- Westmead Hospital
4. Westmead Hospital- Primary Survey Airway: Speaking in sentences, hoarse voice. No stridor/resp distress. Trachea and uvula deviated to left. No subcut emphysema or crepitus No drooling/odynophagia/dysphagia Zone 3 R sided puncture wound over SCM B: SaO2 100% RA, equal air entry, normal RR, no respiratory distress
5. Primary Survey (cont.) C: HR 97, BP 180/70; non-expanding non-pulsatile R neck swelling in SCM, no bruit heard D: GCS 15/15, vocal hoarseness and deviated uvula, moving all limbs spontaneously, no focal neurological deficits, no other cranial nerve abnormalities
6. Secondary Survey Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness Chest: No chest tenderness, equal AE, vesicular breath sounds Abdomen: soft, non-tender Pelvis: stable and non-tender Upper & lower limbs: NAD
7. Evaluation Zone 3 penetrating neck trauma (above angle of mandible) Potential airway compromise due to extrinsic haematoma Moderate-high risk for vascular neck injury due to location of entry wound and haematoma No sign of acute life threatening vascular compromise (exsanguination/haemorrhage/stroke)
8. Management Urgent assessment of airway No stridor or respiratory distress Nasendoscopy performed by ENT: Oropharyngeal haematoma with mild swelling Normal vocal cords & movement Normal cranial nerves No need for immediate intubation, if any deterioration for anaesthetic r/v and gaseous intubation Deemed stable for transfer to CT angiography with medical escort
9. Management (cont) IV dexamethasone to minimise airway oedema O2 therapy via Hudson mask 2x large bore cannulae; 1L of Hartmann’s administered intravenously; analgesia ADT and cephazolin administered
11. Imaging report 2x metallic foreign bodies- one at level of C2, one embedded in SCM 6mm ECA pseudoaneurysm 2.5cm above angle of mandible
12. Further management Admission to ICU for airway, circulatory and neuro observations Vascular consultation Aspirin Semi-electively 3-4 days post injury R Cerebral & carotid angiogram for management of pseudoaneurysm with coiling performed. No immediate complications; d/c home on oral antibiotics
14. Presentation to WMH- Major Trauma Call 58M awoken by partner stabbing his R neck with kitchen knife Walk in to ED Major trauma call on arrival
15. Primary Survey Airway: Speaking in sentences No stridor; no tracheal deviation 2cm laceration upper zone 2 over R SCM with small non-pulsatile non-expanding haematoma No active bleeding No crepitation/emphysema No dysphagia/odynophagia/drooling Breathing: SaO2 95%, equal air entry, vesicular breath sounds, no respiratory distress
16. Primary Survey (cont) C: HR 80, BP 140/85, small haematoma at area of stab wound D:GCS 15/15, moving all limbs spontaneously, no focal neurological deficits, no cranial nerve abnormalities
17. Secondary Survey Head, neck, face: findings as above; no other injuries seen; no cervical spine tenderness Chest: No chest tenderness, equal AE, vesicular breath sounds Abdomen: soft, non-tender Pelvis: stable and non-tender Upper & lower limbs: NAD
18. Evaluation Zone 2 penetrating neck trauma (between cricoid cartilage and angle of mandible) Stable from airway/breathing/circulatory perspective Potential injury to anterior neck vasculature Deemed safe for transfer for CT angiogram of head and neck
19. Management 6L O2 via Hudson Mask 2x large bore cannulae, IV Hartmann’s solution IV cephazolin, ADT NBM CT angiogram of head & neck performed
21. Imaging report 26mm x 20mm x 15mm subcutaneous haematoma anterolateral to R SCM superficial to inferior aspect of parotid gland Small locule of gas in R SCM Vessels intact
22. Further Management HDU admission for airway, circulation observations For exploration of neck wound with ASU and vascular team early the next day
23. Operative Findings Expanding R anterior neck haematoma- evacuated Stab wound tract explored- penetration through platysma to lacerated sternocleidomastoid belly Dissection to R IJV- intact R ICA, vagus nerve, identified- intact
24. Further Progress Returned to HDU postoperatively for airway & circulatory monitoring No immediate postoperative complications Discharged the next day on oral antibiotics
25. 25% of head/neck trauma 5-10% all arterial injury Carotid injury- 10-30% mortality; 15-60% permanent neurologic deficit Vascular Neck Injuries
26. Relevant Anatomy ICA, ECA Jugular vv Lat pharynx Cr VII, IX, X, XI, XII CCA ICA, ECA Jugular vv Larynx Hypopharynx Cr X, XI, XII Subclaa & vv Jugular vv CCA Trachea Oesophagus, thyroid
29. Vascular traumatic injuries Complete or partial transection Intimal flap/dissection Aneurysm Pseudoaneurysm Fistula Extrinsic compression Thromboembolism as a result of intimal injury
30. Sequelae Haemorrhage Airway compression, exsanguination, concealed haematoma Distal ischaemia Either due to vessel injury or thromboembolism Strokes- ACA/MCA (carotid injury), PCA/posterior (vertebral injury) Damage to nearby structures
31. Penetrating neck injury (>90%) Injuries through platysma indicate propensity for injury to deep structures Gunshot wounds and projectiles Low velocity- unpredictable trajectory High velocity Cavitation and blunt type injury from concussive forces Stab/knife Straight and more obvious path Less tissue damage
32. Blunt Neck Trauma (<10%) Seatbelt injury Hanging/ligature/strangulation Punching/kicking Hyperextension/hyperrotation/contusion Mechanism is translocational & shear forces Spectrum from intimal injury (more common) to transection (less common)
33. Associated with dislocation/fracture Mandibular, temporal bone fractures can be a/w carotid/jugular injury Vertebral aa injury in general rare- usually a/w C-spine pathology #C-spine (inc Lateral mass #) Ligamentous injury Rotation/hyperextension Near-hanging Extreme chiropractic manoevres
34. Iatrogenic injury CVC insertion Cerebral Angiography C-spine surgery, transsphenoidal, skull base surgery Radiotherapy (stenosis) Nerve blocks (vertebral aa injury)
37. Airway High comorbidity with airway injury & compromise Assess for: Airway patency- stridor, resp distress, hoarseness Expanding haematoma Emphysema/crepitus/drooling/dysphagia ENT r/v if possible (+/- nasendoscopy) May require trache(/cricothyroidotomy/intubation), exploration or stenting If unstable will require emergent OT +/- trache
38. Breathing General principles apply Give Supplemental O2 Optimise tissue O2 delivery Assess chest expansion & for subcut emphysema Need CXR May have comorbid chest injury in high risk mech (eg MVA) Zone 1- risk of assochaemo/pneumothorax Index of suspicion for aspiration
39. Circulation General principles of resuscitation apply Large bore IV access Fluid resuscitation, Xmatch, possible transfusion Direct compression of severe external bleeding- finger/foley catheter in wound If unstable – immediate OT
40. Circulation (cont) Assess for “Hard” signs of vascular injury Pulsatile bleeding or haematoma Expanding haematoma Shock + ongoing bleeding Absent pulses Neurovascular symptoms- stroke/TIA symptoms Thrills, bruits
41. Circulation (cont) “Soft” signs – warrant further investigation Severe bleeding from neck/pharynx Diminished pulses- superficial temp artery Small haematoma Fractures of skull base, temporal bone, fracture d/location C-spine Injury in anatomical area Ipsilateral Horner’s Cranial IX-XII dysfunction Widened mediastinum
42. Disability If suspicion of C-spine injury- hard collar Focal neurology in stroke territoryshould alert to possible vasc injury Cranial nerve VII --> XII (except VIII) Horner’s syndrome (compression of cervical chain) Brachial plexus injury
43. Other Injuries on Secondary Survey Aerodigestive – oesophagus & pharynx Drooling Odynophagia, dysphagia
44. Summary Airway injury/compromise common and may r/q emergent management If unstable from airway/circulatory point of view needs immediate operative management including exploration Expanding haematoma may cause airway compromise Stroke symptoms, bruits, thrills are a hard sign of vascular injury If stable can go on to have further imaging
48. Scanning Duplex USS useful for Zone 2 injuries- unhelpful for Z1 or 3 CT brain & CTA neck CT angiogram may show aneurysm, dissection, fistulae etc (esp with blunt trauma) or occult injury Localisation of FB CT brain valuable predictor of outome- infarct on CTB has high mortality, poor neurologic prognosis
50. Supportive/preop care Nurse in HDU environment Supplemental O2 Fluid resuscitation Correct hypoglycaemia Anticoagulation for intimal injuries- high risk of thromboembolism; IV heparin followed by 3/12 warfarin
51. Operative management Mandatory exploration of penetrating neck wounds beyond platysma used to be gold standard- 1800’s till 1980’s Fogelman & Stewart (1956)- 6% mortality with mandatory exploration, 35% without In 1980’s- increasing operations with negative findings More selective approach adopted now
52. Indications for urgent surgery Airway compromise Haemodynamic instability Active pulsatile haemorrhage Expanding haematoma
53. Indications for surgery (other) Arterial injury requiring primary repair High index of suspicion of injury Gunshot wounds, penetration through midline Ongoing bleeding Need for exploration of other structures
54. Indications for angiography +/- endovascular intervention Assessment of zone 1 & zone 3 injuries unable to be visualised otherwise Embolisation of persistent ECA bleeding Embolisation of osseusverterbal canal vert aa injury Covered stentgrafts- penetrating wounds/AVF’s/pseudoaneuryms in surgically inaccessible areas, patients who are unfit for surgery, injury to brachiocephalic trunk, proximal CCA/SCA
55. Procedure Supine position, bolster between scapulae, neck extended, head rotated; access from base of skull to xiphisternum Zone 1- oblique supraclavicular incision; may require median sternotomy; thoracic surgical referral Zone 2- standard carotid incision- anterior border of SCM Zone 3- similar to Z2 but may r/q mandibulotomy or subluxation; 2cm below mid mandible, 1cm facial notch (avoid marginal br facial nn) Arteries should be repaired (primarily if possible; bypass if simple repair not possible) ECA may be ligated if necessary (if ICA ok) Venous injuries (inc IJ) may be ligated. Complex venous repair not recommended If trachea/oesophagus injured, repair should be protected by SCM
