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

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Vascular neck trauma

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Editor's Notes

  1. Anterior triangle vs post triangleLayers of neck