1. Department of surgery
Songkhla hospital

3.  Superficial cervical fascia - platysma
 Deep cervical fascia
◦ Investing : sternocleidomastoid muscle, trapezius
muscle
◦ Pretracheal : larynx, trachea, thyroid gland,
pericardium
◦ Prevertebral : prevertebral muscles, phrenic nerve,
brachial plexus, axillary sheath
◦ Carotid sheath : carotid artery, internal jugular
vein, vagus nerve

7.  Wounds that penetrate the platysma must be
further evaluated
 The major vascular and aerodigestive structures
in the neck are located in the anterior triangle, and
all are deep to the platysma
 Penetrating injuries to the posterior triangle should
raise concern about trauma to the cervical spine
and spinal cord

9.  Zone I is the thoracic inlet from the sternal notch
to the cricoid cartilage
 Zone II is the midportion of the neck from the
cricoid cartilage to the angle of the mandible
 Zone III extends from the angle of the mandible to
the base of the skull

10.  Zone I
◦ Contains the subclavian arteries and veins, the dome
of the pleura, esophagus, great vessels of the neck,
recurrent nerve, trachea
 Zone II
◦ Contains the larynx, pharynx, base of tongue, carotid
artery and jugular vein, phrenic, vagus, and
hypoglossal nerves
 Zone III
◦ Contains the internal and external carotid arteries, the
vertebral artery, and several cranial nerves

13.  Does the patient require emergent airway
protection?
 What is the best approach and technique for
airway protection?

14.  Airway compromise (eg, respiratory distress,
severe hemorrhage, extensive or sucking neck
wound, shock)
 Definite airway should be perform such as
orotracheal tube or surgical airway
 Surgical airway is recommended if significant
trauma or obstruction above the larynx or if
anatomy is sufficiently distorted and airway
cannot be identified

15.  Significant bleeding or hematoma
 Hemoptysis
 Subcutaneous emphysema
 Bruit or thrill
 Neurologic deficit
 Distorted neck anatomy
 Stridor
 Difficulty or pain when swallowing secretion
 Abnormal voice especially hoarseness(hot potato
voice)

16. Method
 Oral & nasal intubation with or without endoscopic
guidance or muscle relaxants
 Surgical airway

17. Surgical airway
◦ Cricothyrotomy (life saving procedure ,
temporary airway)
◦ Tracheostomy

18.  Zone I injuries with concomitant thoracic
injuries
◦ pneumothorax
◦ hemopneumothorax
◦ tension pneumothorax

19.  Bleeding should be controlled by pressure
 Do not clamp blindly or probe the wound depths
 The absence of visible hemorrhage does not rule
out
 Two large bore IVs

20.  Thorough head and neck exam using palpation
and stethoscope to search for thrills and bruits
 Neuro exam: mental status, cranial nerves, and
spinal column
 Examine the chest, abdomen, and extremities

21.  Be sure to examine the back of the patient as
unsuspected stab or gunshot wounds have been
missed here
 Don’t blindly explore wound or clamp vessel

22. Unstable patient
Immediate transfer to the OR
Stable patient
◦ Mandatory exploration
◦ Selective approach

24.  Vascular injury Shock Hematoma
Hemorrhage
Pulse deficit
Neurologic deficit
Bruit or thrill in neck
 Laryngotracheal injury Subcutaneous emphysema
Airway obstruction
Sucking wound
Hemoptysis
Dyspnea
Stridor
Hoarseness or dysphonia
 Pharynx/esophagusinjurySubcutaneous emphysema
Hematemesis
Dysphagia or odynophagia

25.  X-Rays
◦ Pneumothorax or hemothorax
◦ retropharyngeal air or pneumomediastinum,
suggests esophageal injury

26.  CT neck
◦ A multidetector helical CT scan (MDCT)
is often the first study obtained because
it can detect laryngotracheal, vascular,
and esophageal injuries simultaneously
and rapidly

27.  Esophagography
◦ All penetrating neck injuries due to
high incidence of occult
esophageal injuries
 Endoscopy
◦ If swallow (-), enhances sensitivity
for penetrating esophageal injury

28.  CT-Angiogram
◦ The sensitivity and specificity of CT-A for
detecting significant vascular wounds in the
neck approaches nearly that of standard
angiography

29.  Angiography
◦ Angiography demonstrates sensitivity and
specificity of close to 100 percent and has
been considered the gold standard in stable
patients

30.  Endoscopy or laryngoscopy
◦ alternatives for the diagnosis of LT trauma