PNT

1. PENETRATING NECK TRAUMA
PRESENTED BY DR. KARIM

2. Introduction
i. Penetrating Trauma from clavicles to skull base (neck) .
ii. PNT is a relatively uncommon inj with significant morbidity and
possible mortality .
iii. There is no international guidelines on PNT management.
iv. Surgical management for PNT has evolved the last two decades
, based on the advent of advanced radiographic studies and
endoscopic techniques.
v. Management of PNT is a big challenging issue for emergency
physicians , due to two reasons location of vital structures and
critical inj and vascular management .
vi. Anatomy of the Neck region is very necessary .

3. Epidemiology
 1.7 % all trauma patients have PNT
 Male 4 * Female
 GSW about 24-48 % Cause of inj
 Stab wound about 40 – 75 % cause of inj
 GSW is responsible for 50 % significant inj and often critical inj
 Stab inj responsible for 10-20% significant inj and less critical inj
 All PNT have 1,3 – 3 % mortality
 Major vascular inj have 50 % mortality
 Wounded age average 30 y
 Zone II inj = about 38- 67 %
 Zone III inj = about 16-19%
 Zone I inj 13-18%

4. Epidemiology
 Approximately 10 % of patients present with air way compromise.
 Isolated Cervical spin inj in PNT are uncommon.
 7% of wounded have cervical spin inj .
 Unstable cervical spin inj are rare < 0,5 %
 Arterial inj about 25 % of all PNT
 Carotid artery is 80 % involve & Vertebral artery is 43% involve of
25% arterial inj
 Aero digestive structures inj occurs about 23-30% of all PNT
 Neurologic structures inj occurs about 20 %

5. Surgical anatomy of neck
 Skin
 Fascial Layer of the neck
 Platysma muscle ( Ext Jugular vein is located superficial …)

6. Fascial layer of the neck
 Fascia is the internal connective tissue forms sheets.
 Support internal structures of the neck .
 Compartmentalizes structures of the neck .
 Superficial cervical layer or fascia & deep cervical fascia

7. Deep Cervical Fascia
 Lies deep to the superficial fascia and platysma muscle .
 Acts like a shirt collar , supporting the structures and vessels of the
neck .
 Organized into several layers .
1. Investing layer , lies superficial , can be thought like a tube.
2. pretracheal layer , situated in the ant neck , fuses with pericardium,
trachea , esophagus , thyroid gland , infra hyoid muscle enclosed by it
.
3. Prevertebral fascia , surrounds vertebral column , its associated
muscles , surrounds the brachial plexus as it leaves the neck and
subclavian artery as it pass through the lower neck region (forms
axillary sheath.
4. Carotid sheath (enclosed Common carotid artery , Int jugular vein
and vagus nerve .

8. Pretracheal layer (fascia)

9. Prevertebral fascia

10. Carotid sheath and triangle

11. Neck triangles
 Anterior trisngle
 Posterior triangle
Carotid triangle

12. Anterior triangle
Its contents : Common carotid artery & its bifurcation
Internal jugular vein
Cranial nerve = VII , IX , X , XI , XII

13. Posterior triangle
It’s contents : subclavian vein + artery
Transvers cervical vein +artery
Supra scapular vein + artery
Cranial nerve XI Accessory N
Brachial plexus
Cervical plexus (Phrenic N)

14. Carotid triangle
It’s contents : common carotid artery
Internal jugular vein
Vagus N

15. Neck Zones

16. Zone I
o Most caudal anatomic zone
o Structure within this zone include the :
1. Proximal common carotid artery .
2. Vertebral and subclavian arteries .
3. Subclavian , innominate , and jugular vein .
4. Recurrent laryngeal N & Vagus N
5. Esophagus
6. Thoracic duct
 Vascular inj Mangement is challenging in this zone .
 High mortality
 Due to the sternum , surgical access to zone I may require sternotomy
or thoracotomy to control hemorrhage .
 Needle thoracostomy .
 check the upper limbs .

17. Zone II
1. Middle anatomic zone
2. Vertical & horizontally neck exploration incision provide surgical
access to this zone .
It’s contains :
carotid artery
jugular and vertebral vein , pharynx , & larynx
Recurrent laryngeal & Vagus N
spinal cord

18. Zone III
1. The cephald anatomic zone
2. Vascular access in this zone is difficult, some time require
craniotomy , mandibulotomy or maneuvers to displace
anteriorly the mandible .
3. Anatomic structures in this zone are :
 Extra cranial carotid & vertebral artery
 Jugular vein
 spinal cord
 cranial nerve IX , XII
 sympathetic trunk

19. Type of inj (pathophysiology)
Etiology divided : 1- high velocity mechanism
-- cause critical inj , make temporary cavity &
permanently cavity inside the wound
2- low velocity mechanism
---just make permanently cavity inside the
wounds , and injure the neck structures on the
projectile victor .
3 – vascular structures injured by both , direct &
indirect trauma (temporary cavity & shear force )
primary & secondary after the time of injury .

20. Primary and secondery
vascular pathology
Primary vascular inj :
 vessel es transection
 vessel es laceration
 vessel es puncture
 vessel es intimal flap
 pseudo aneurysm
Secondary vascular inj :
thrombosis , arterovenus fistula formation , pseudo
aneurysm .

21. Clinical Feature
‫میباشد‬ ‫ذیل‬ ‫های‬ ‫حالت‬ ‫دو‬ ‫از‬ ‫انتروال‬ ‫یکی‬ ‫به‬ ‫عنق‬ ‫نافذه‬ ‫تروما‬ ‫مجروحین‬.
1-‫اعراض‬ ‫بدون‬ ‫نسبی‬ ‫طور‬ ‫به‬ ‫و‬ ‫ثابت‬ ‫هیمودینامیک‬ ‫حالت‬ ‫به‬
2-‫شاک‬ ‫درحالت‬ ‫مریضان‬–‫هوایی‬ ‫طرق‬ ‫تشوش‬ ‫و‬ ‫خونریزی‬

22. Aero digestive & vascular Hard & soft sign
Hard sign Soft sign
Air way compromise Stable hematoma
Massive subcutaneous emphysema Mild hypotension
Air bubbling through the wound Un explained altered mental
status
Expanding or pulsatile hematoma Focal neurologic deficit
Active bleeding Prehospital bleeding from inj
shock ‫نزدیک‬‫شریان‬ ‫موقیعت‬ ‫به‬ ‫جرحه‬ ‫بودن‬
‫داخلی‬ ‫جگوالر‬ ‫ورید‬ ‫و‬ ‫کاروتید‬
Neurologic deficit Subtle neurologic deficit

23. Hard sign Soft sign
Stridor Audible bruit and palpable thrill
inside the inj
dyspnea Absent or diminished peripheral
pulse
Shock Deep neck pain
Pain or difficulty when swallowing
Hematemesis
Change of Voice
Odynophagia
Laryngeal crepituse
Dysphagia
hemoptysis
Cervical or mediastina air –x ray
hoarseness

24. Decision for management in PNT patient

27. Prehospital Management
 Patient with PNT can decompensate rapidly & should be transported
immediately to a trauma center .
 Impaled object should not be removed in the field .
 Systemic approach to the management of PNT is critical .
 The initial evaluation and assessment involves resuscitation in
accordance with the ATLS principles .

28. Air way Management
 Airway obstruction
 Secretion or blood in respiratory tract
 Fracture or inj of larynx
 Massive sub cutaneous emphysema
 Trachea deviation
 Expanding hematoma
 Altered mental status
 Soft tissue distortion
 Changes of voice
 Stridor
 Hemoptysis

29. Air way management
I. Orotrachail intubation
II. intermittent suction
III. Tracheotomy and tracheostomy
IV. Cricothyroidotomy
V. Supra glottis air way
VI. Up right position
VII. Trachial tube placement through the wound of trachea
VIII. Avoid and do not use bag valve mask

30. ‫شود‬ ‫گرفته‬ ‫نظر‬ ‫در‬ ‫هوایی‬ ‫طرق‬ ‫منجمنت‬ ‫جریان‬ ‫در‬ ‫باید‬ ‫که‬ ‫نقاط‬.
1-‫کی‬ ‫جروحاتو‬ ‫نافذه‬ ‫په‬ ‫عنق‬ ‫د‬ ‫چه‬ ‫دا‬
-‫خوری‬ ‫برهم‬ ‫له‬ ‫اناتومی‬ ‫نارمل‬–‫وی‬ ‫موجود‬ ‫هیماتوم‬–‫جریان‬ ‫خونریزی‬ ‫فعاله‬
‫لری‬–‫وی‬ ‫مختل‬ ‫شعور‬–‫وی‬ ‫موجوده‬ ‫حنجری‬ ‫د‬ ‫یا‬ ‫تراکیا‬ ‫د‬ ‫جرحه‬–‫وینه‬ ‫یا‬ ‫افرازات‬
‫وی‬ ‫موجوده‬ ‫کی‬ ‫لیاره‬ ‫هوایی‬.
‫چی‬ ‫ده‬ ‫مشکله‬ ‫زیاته‬ ‫لپاره‬ ‫داکتر‬ ‫تجربه‬ ‫با‬ ‫زیات‬ ‫د‬ ‫حتی‬ ‫کی‬ ‫حاالتو‬ ‫پورتنی‬ ‫په‬
‫شی‬ ‫وکوالی‬ ‫منجمنت‬ ‫هوایی‬ ‫طرق‬–‫تجربه‬ ‫اندازه‬ ‫کافی‬ ‫باید‬ ‫اساس‬ ‫همدی‬ ‫په‬
‫ولرو‬ ‫وسایل‬ ‫کافی‬ ‫ورسره‬ ‫او‬ ‫مهارت‬ ‫او‬.
2-‫طرق‬ ‫شی‬ ‫کیدای‬ ‫چه‬ ‫دا‬ ‫بل‬ ‫وی‬ ‫نه‬ ‫نارمله‬ ‫کی‬ ‫جروحاتو‬ ‫دی‬ ‫په‬ ‫اناتومی‬ ‫چه‬ ‫دا‬
‫ولری‬ ‫جرحه‬ ‫خپله‬ ‫هوایی‬–‫د‬ ‫هم‬ ‫یا‬ ‫او‬ ‫انتوبیشن‬ ‫کاذب‬ ‫د‬ ‫انتوبیشن‬ ‫کورانه‬ ‫کور‬
‫شی‬ ‫کیدای‬ ‫مخامخ‬ ‫سره‬ ‫خطر‬ ‫زیات‬ ‫ال‬ ‫د‬ ‫جرحه‬ ‫حنجری‬ ‫یا‬ ‫تراخیا‬–‫زیات‬ ‫نو‬
‫دی‬ ‫کار‬ ‫په‬ ‫احتیاط‬.
3-‫د‬ ‫وینی‬ ‫د‬ ‫انتوبیشن‬ ‫کی‬ ‫شتون‬ ‫په‬ ‫هیماتوم‬ ‫د‬ ‫عنق‬ ‫د‬ ‫واوسو‬ ‫متوجه‬ ‫باید‬ ‫ته‬ ‫دی‬
‫شی‬ ‫کیدای‬ ‫سبب‬ ‫خونریزی‬ ‫دوباره‬ ‫او‬ ‫کیدو‬ ‫خطا‬ ‫د‬ ‫علقی‬.
4-‫هوایی‬ ‫د‬ ‫وجه‬ ‫په‬ ‫افرازاتو‬ ‫داخلی‬ ‫او‬ ‫خونریزی‬ ‫داخلی‬ ‫د‬ ‫انتوبیشن‬ ‫تر‬ ‫وروسته‬
‫دی‬ ‫ممکن‬ ‫بندش‬ ‫لیاری‬–‫شته‬ ‫ضرورت‬ ‫ته‬ ‫سکشن‬ ‫ییی‬ ‫قفه‬ ‫و‬ ‫لپاره‬ ‫دهمدی‬.

31. Breathing
 Pneumothorax
 Hemothorax
 Mediastina hematoma
Usually in Zone I PNT can cause of respiratory Failure :
Needle decompression is necessary sometime
‫شود‬ ‫گرفته‬ ‫نظر‬ ‫در‬ ‫رابطه‬ ‫در‬ ‫باید‬ ‫که‬ ‫نقاط‬.
1
-‫زدن‬ ‫سوزن‬ ‫جهت‬ ‫درست‬ ‫موقیعت‬ ‫انتخاب‬
2-‫بزرگتر‬ ‫گیج‬ ‫با‬ ‫سوزن‬ ‫داشتن‬
3–‫بی‬ ‫و‬ ‫اسان‬ ‫زدن‬ ‫سوزن‬ ‫صدر‬ ‫جنب‬ ‫ناحیه‬ ‫در‬ ‫صدر‬ ‫نازک‬ ‫جدار‬ ‫داشتن‬ ‫به‬ ‫نسبت‬
‫بود‬ ‫خواهد‬ ‫خطر‬.

32. Vascular management
Bleeding should stop in Prehospital care :
1- Direct pressure
2 – Dressing with paraffin gauze which prevent air embolisms
particularly when vien is involve .
3- Use folly catheter , it is most useful technique .
‫انتقال‬ ‫د‬ ‫نباید‬ ‫او‬ ‫دی‬ ‫نه‬ ‫ضروری‬ ‫کی‬ ‫وخت‬ ‫دی‬ ‫په‬ ‫رسی‬ ‫الس‬ ‫ورته‬ ‫یا‬ ‫نیول‬ ‫ورید‬
‫کو‬ ‫ضایع‬ ‫ورباندی‬ ‫وخت‬.‫وکوو‬ ‫کار‬ ‫دا‬ ‫لیاره‬ ‫پر‬ ‫کی‬ ‫وخت‬ ‫په‬ ‫انتقال‬ ‫د‬ ‫شی‬ ‫کیدای‬.
( prolong on scene time )
( Scoop and run )

33. Cervical spine immobilization
 spine immobilization is controversial because :
1- incidence the cervical spines inj in PNT are rare
2 – Most of cervical spine inj are stable
3- It’s waste the time of transport about (2.5- 5 ) min
‫کو‬ ‫تعقیب‬ ‫او‬ ‫ارزیابی‬ ‫توگه‬ ‫مستقیم‬ ‫په‬ ‫جرحه‬ ‫عنق‬ ‫د‬ ‫کوالی‬ ‫نشو‬.
‫کوی‬ ‫مداخله‬ ‫کی‬ ‫کنترول‬ ‫او‬ ‫کی‬ ‫منجمنت‬ ‫په‬ ‫لیار‬ ‫هوایی‬ ‫د‬.
‫کوی‬ ‫وروسته‬ ‫تشخیص‬.
‫کوالی‬ ‫نشو‬ ‫ارزیابی‬ ‫هیماتوم‬ ‫د‬ ‫عنق‬ ‫د‬.
‫شته‬ ‫استثنا‬ ‫یو‬–‫کو‬ ‫تثبیت‬ ‫فقرات‬ ‫باید‬ ‫وی‬ ‫موجود‬ ‫تشوشات‬ ‫نیورولوژیک‬ ‫چیری‬ ‫که‬.
‫کی‬ ‫ضابع‬ ‫وخت‬ ‫انتقال‬ ‫د‬ ‫مجروح‬ ‫د‬ ‫نباید‬ ‫تثبت‬ ‫فقراتو‬ ‫رقبی‬ ‫د‬ ‫باالخره‬.

34. Emergency Department management
1-Follow the ATLS principles) A,B,C,D,E,)
2-‫باشد‬ ‫حیات‬ ‫کننده‬ ‫تهدید‬ ‫حاالت‬ ‫با‬ ‫توجه‬.
3–‫نمایید‬ ‫اجرا‬ ‫ضروری‬ ‫های‬ ‫کمک‬ ‫تروما‬ ‫تیم‬ ‫اعضا‬ ‫همه‬ ‫باید‬ ‫همزماه‬.
4–‫میگردد‬ ‫دوباره‬ ‫خونریزی‬ ‫باعث‬ ‫گردد‬ ‫تفتش‬ ‫عاجل‬ ‫اطاق‬ ‫در‬ ‫نباید‬ ‫جرحه‬.
5-‫باشد‬ ‫هوایی‬ ‫طرق‬ ‫کنترول‬ ‫و‬ ‫خونریزی‬ ‫کنترول‬ ‫در‬ ‫تمرکز‬ ‫باید‬ ‫ها‬ ‫کمک‬ ‫اجرا‬ ‫در‬.
6–‫باشد‬ ‫داشته‬ ‫خاص‬ ‫ضیعت‬ ‫و‬ ‫باید‬ ‫مریض‬ ‫هوایی‬ ‫امبولی‬ ‫از‬ ‫جلوگیری‬ ‫جهت‬.
7-‫شود‬ ‫گرفته‬ ‫مقابل‬ ‫طرف‬ ‫در‬ ‫باید‬ ‫مایعات‬ ‫تطبیق‬ ‫جهت‬ ‫ورید‬.
8-‫نگردد‬ ‫تطبیق‬ ‫است‬ ‫بهتر‬ ‫مری‬ ‫جروحات‬ ‫تشخیص‬ ‫تا‬ ‫انفی‬ ‫تیوب‬.
9-‫طرق‬ ‫باید‬ ‫ان‬ ‫از‬ ‫قبل‬ ‫باشد‬ ‫داشته‬ ‫نیاز‬ ‫عاجل‬ ‫جراحی‬ ‫به‬ ‫مریض‬ ‫که‬ ‫صورت‬ ‫در‬
‫گردد‬ ‫کنترول‬ ‫کتیتر‬ ‫فولی‬ ‫یا‬ ‫مستقیم‬ ‫فشار‬ ‫توسط‬ ‫فعال‬ ‫خونریزی‬ ‫و‬ ‫کنترول‬ ‫هوایی‬.
10–‫در‬ ‫ولی‬ ‫است‬ ‫کم‬ ‫عنق‬ ‫جروحات‬ ‫در‬ ‫مرکزی‬ ‫موقیعت‬ ‫نسبت‬ ‫مری‬ ‫جروحات‬
‫زیاد‬ ‫جروحات‬ ‫مس‬ ‫بنا‬ ‫ندارد‬ ‫تشخیصیه‬ ‫و‬ ‫بارز‬ ‫عالیم‬ ‫باشد‬ ‫داشته‬ ‫جرحه‬ ‫که‬ ‫صورت‬
‫سیپس‬ ‫و‬ ‫منصف‬ ‫التهاب‬ ‫باعث‬ ‫از‬ ‫دارد‬ ‫درقبال‬ ‫زیاد‬ ‫میر‬ ‫مرگ‬ ‫که‬ ‫دارد‬...

35. speech
stridor
shortness of breath
Bubbling wound
Subsutaneus Empysema
Surgical Crepitus
Haemoptysis
Pneumothorax
Bleeding (‫مستقیم‬ ‫فشار‬ ‫توسط‬ ‫خونریزی‬ ‫توقف‬ )
Hematoma (Expanding or pulsatile)
Bruits
Carotid inj ( Hornor syndrom)
Unilateral absent radial pulse
Arterial - brachial index(<90)
Pain on Swallowing
Heamatemesis
Cranial nerve
Hornors Syndrom
Recurrent laryngeal Nerve
Brachial plexus
Phrenic Nerve
Long Tract sign
Air way
Vascular
Oesophageal
Neurological
) Clinical assessment ( ‫گردد‬ ‫معاینه‬ ‫روتین‬ ‫شکل‬ ‫به‬ ‫باید‬ ‫ذیل‬ ‫عالیم‬

36. Diagnostic imaging
 Direct laryngoscopy
 Video laryngoscopy
 Fiber optic laryngoscopy
Bronchoscopy
 Oesophagoscopy
 Angiography
CT

37. Surgeons
 Trauma surgeon
 Neurosurgeon
 vascular surgeon
 General surgeon
 ENT surgeon
 Anesthesia Experts

51. References
1- ATLS
2- Chapter 7 penetrating & blunt neck trauma
Nathan L.Salinas, MD, captain,MC, USA
Joseph A, BrennamMD, Colonel, MC,USAF
3-Penetrating neck traum (Royal college of surgeons)
4-WTA (critical decisionin in trauma: penetrating neck trauma)
5- RELIAS MEDIA penetrating neck trauma
6-VENTURA COUNTY MEDICLA CENTER TRAUM DEPARTMENT
7-REBELEM 2018
8- Teach me anatomy