author(s): patrick carter, daniel wachter, rockefeller oteng, carl seger, 2009-2010. license: unless...

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Advanced Emergency Trauma Course

Ghana Emergency Medicine Ghana Emergency Medicine CollaborativeCollaborative

Patrick Carter, MD Patrick Carter, MD ∙ ∙ Daniel Wachter, MD Daniel Wachter, MD ∙ ∙ Rockefeller Oteng, MD Rockefeller Oteng, MD ∙∙ Carl Seger, MDCarl Seger, MD

Penetrating and Blunt Neck Trauma

Presenter: Rockefeller Oteng, MD

Ghana Emergency Medicine Collaborative


Lecture Objectives

The discuss the different The discuss the different mechanisms of injurymechanisms of injury

To review the anatomy of the To review the anatomy of the neck neck

To discuss the types of To discuss the types of injuries related to blunt and injuries related to blunt and penetrating mechanismspenetrating mechanisms

Discuss management techniquesDiscuss management techniques





Epidemiology

This is an area in which there This is an area in which there isnisn’’t a great deal of t a great deal of informationinformation

In the U.S. itIn the U.S. it’’s suggested that s suggested that neck trauma accounts for 5%-10% neck trauma accounts for 5%-10% of all serious traumatic of all serious traumatic injuriesinjuries

Predominance is towards men Predominance is towards men from 20 to 30 years of agefrom 20 to 30 years of age



Epidemiology

Neck injuries can be very deceivingNeck injuries can be very deceiving Seemingly minor injuries can Seemingly minor injuries can quickly become life threatening.quickly become life threatening.

There are a great deal of vessels There are a great deal of vessels from all the different body systems from all the different body systems in this tight spacein this tight space

The insidious nature of injury to The insidious nature of injury to this area often leads to a delay in this area often leads to a delay in diagnosisdiagnosis





Anatomy

Given the critical nature of Given the critical nature of the contents of the neck, there the contents of the neck, there is a need for a systematic is a need for a systematic approach to evaluation and approach to evaluation and managementmanagement

This approach is based on a This approach is based on a good understanding of the good understanding of the underlying anatomy underlying anatomy





Anatomy

Neck contents are contained by Neck contents are contained by two discrete fascial layers: two discrete fascial layers: • The superficial fascia :The superficial fascia :

Which envelops the platysma muscle. Which envelops the platysma muscle.

• The deep cervical fascia:The deep cervical fascia: Contains the sternocleidomastoid and Contains the sternocleidomastoid and trapezius muscles.trapezius muscles.

It is also used to mark the pretracheal It is also used to mark the pretracheal region which includes the trachea, region which includes the trachea, larynx, thyroid gland, and pericardiumlarynx, thyroid gland, and pericardium





Anatomy

Deep facial contents Deep facial contents continued:continued:•It invests the prevertebral It invests the prevertebral area area Containing the prevertebral Containing the prevertebral muscles, phrenic nerve, brachial muscles, phrenic nerve, brachial plexus, and axillary sheathplexus, and axillary sheath

The carotid sheath encloses the The carotid sheath encloses the carotid artery, internal jugular carotid artery, internal jugular vein, and vagus nerve.vein, and vagus nerve.





Anatomy

The platysma, which The platysma, which is a very thin is a very thin muscle, covers the muscle, covers the entire anterior entire anterior triangletriangle

Lies just beneath Lies just beneath the subcutaneous the subcutaneous tissuetissue

Is an important Is an important landmark when landmark when evaluating evaluating penetrating neck penetrating neck injuriesinjuries



Gray’s Anatomy (Wikipedia)



http://commons.wikimedia.org/wiki/File:Platysma.png

Anatomy There are several way in which to There are several way in which to describe the neck anatomydescribe the neck anatomy

Classic anatomist describe the triangles:Classic anatomist describe the triangles:• Anterior TriangleAnterior Triangle:: Bound superiorly by:Bound superiorly by:

MandibleMandible Anterior border of the sternocleidomastoid Anterior border of the sternocleidomastoid musclemuscle

Midline of the neckMidline of the neck

• Posterior Triangle:Posterior Triangle: Posterior sternocleidomastoid musclePosterior sternocleidomastoid muscle Trapezius Trapezius Middle third of the clavicle inferiorly Middle third of the clavicle inferiorly





Anterior Triangle

Important structural contents Important structural contents include:include:1.1. Carotid ArteryCarotid Artery

2.2. Internal jugular veinInternal jugular vein

3.3. Vagus nerveVagus nerve

4.4. Thyroid glandThyroid gland

5.5. LarynxLarynx

6.6. Trachea Trachea

7.7. EsophagusEsophagusGhana Emergency Medicine

CollaborativeAdvanced Emergency Trauma Course



Anterior Triangle



Olek Remesz (Wikipedia)



http://commons.wikimedia.org/wiki/File:Copy_of_Musculi_coli_base,_my_edits_for_tringles,_labeled_trianglesanteriorT.svg

Posterior Triangle

Has fewer vital structural Has fewer vital structural contents:contents:1.1. Subclavian arterySubclavian artery

2.2. Brachial plexusBrachial plexus

Injury to this area can have Injury to this area can have catastrophic outcomescatastrophic outcomes





Posterior Triangle



Olek Remesz (Wikipedia)



http://commons.wikimedia.org/wiki/File:Copy_of_Musculi_coli_base,_my_edits_for_tringles,_labeled_triangles,posterior.svg

Zone Classification



Anatomy classification is excellent Anatomy classification is excellent for describing the static location of for describing the static location of structuresstructures

Injury is not static, and an injury to Injury is not static, and an injury to the neck may enter the anterior the neck may enter the anterior triangle and then pass through the triangle and then pass through the posterior triangle.posterior triangle.

A more useful classification of neck A more useful classification of neck anatomy for trauma is the Zone anatomy for trauma is the Zone classification developed by Roon and classification developed by Roon and ChristensenChristensen



Zone Classification

This classification system can This classification system can guide the clinician in the guide the clinician in the diagnostic and therapeutic diagnostic and therapeutic management management

Based on level of injury to the Based on level of injury to the neck in a caudal to cranial neck in a caudal to cranial orientationorientation

Zone 1:Zone 1:• Lower Border = ClaviclesLower Border = Clavicles• Upper Border = Cricoid CartilageUpper Border = Cricoid Cartilage





Zone I Zone I StructuresZone I Structures

• Vertebral arteriesVertebral arteries• Proximal carotid arteriesProximal carotid arteries• Major thoracic vesselsMajor thoracic vessels• Superior MediastinumSuperior Mediastinum• Lungs, tracheaLungs, trachea• Esophagus Esophagus • Spinal cordSpinal cord• Cervical nerve rootsCervical nerve roots





Zone I



Mysteriouskyn (Wikipedia)

Zone 1

Trauma.org



http://commons.wikimedia.org/wiki/File:Male_neck.jpg

http://www.trauma.org/images/image_library/11199510117Surgery_pictures_006.jpg

http://www.trauma.org/images/image_library/11199510117Surgery_pictures_006.jpg

Zone II

Begins at the inferior portion of Begins at the inferior portion of the cricoid cartilage and extends the cricoid cartilage and extends upwards to the angle of the upwards to the angle of the mandiblemandible

Structures within this area Structures within this area include:include:• Carotid and vertebral arteriesCarotid and vertebral arteries• Jugular veinsJugular veins• Pharynx, larynx, trachea, and esophagusPharynx, larynx, trachea, and esophagus• Cervical spine and spinal cordCervical spine and spinal cord





Zone II



Zone 2

MedScape

Mysteriouskyn (Wikipedia)



Zone III

This zone is located in between This zone is located in between the angle of the mandible and the angle of the mandible and the base of the skullthe base of the skull

Vital structures include:Vital structures include:• Distal carotid arteriesDistal carotid arteries• Vertebral arteriesVertebral arteries• PharynxPharynx• Spinal cordSpinal cord





Zone III



Zone 3

MedScapeMysteriouskyn (Wikipedia)



Initial Management



Initial Management is the same Initial Management is the same as all trauma casesas all trauma cases• Primary survey (ABCDE)Primary survey (ABCDE)• ResuscitationResuscitation• Secondary surveySecondary survey

AirwayAirway• Patients with acute respiratory Patients with acute respiratory distress need a definitive and distress need a definitive and secure airwaysecure airway



Initial management

AirwayAirway• In neck trauma there is sometimes In neck trauma there is sometimes a debate as to when to intervenea debate as to when to intervene

• Blood and air from facial and neck Blood and air from facial and neck injuries can distort the normal injuries can distort the normal anatomic appearance and increase anatomic appearance and increase the difficulty of intubationthe difficulty of intubation





Initial Management

AirwayAirway• Securing the airway should be Securing the airway should be considered if the patient is going to considered if the patient is going to be leaving your supervised areabe leaving your supervised area

• Endotracheal intubation using rapid Endotracheal intubation using rapid sequence technique is the first choice sequence technique is the first choice

• Cricothyrodotomy is second line Cricothyrodotomy is second line treatment when intubation is not treatment when intubation is not successfulsuccessful

• Care should be taken to when intubating Care should be taken to when intubating to avoid an injured tracheato avoid an injured trachea





Initial management AirwayAirway

• If larynx fracture is suspected, If larynx fracture is suspected, immediate cricothyrodotomy may be immediate cricothyrodotomy may be preferredpreferred

• If there is a larynx disruption, If there is a larynx disruption, intubation may result in complete intubation may result in complete transection or creation of a false transection or creation of a false lumenlumen

• An existing tracheostomy site maybe An existing tracheostomy site maybe intubated if availableintubated if available

IF C-SPINE INJURY SUSPECTED, NECK IF C-SPINE INJURY SUSPECTED, NECK SHOULD BE IMMOBILIZEDSHOULD BE IMMOBILIZED





Initial Management BreathingBreathing

• All patients should receive high-flow All patients should receive high-flow oxygen oxygen

• Based on the zone and the proximity to Based on the zone and the proximity to the thoracic inlet, there could be the thoracic inlet, there could be simultaneous injury to the thoraxsimultaneous injury to the thorax

• If you notice any difficulty ventilating If you notice any difficulty ventilating then suspect either upper airway injury then suspect either upper airway injury or thoraxor thorax

• Evaluate for asymmetric breath soundsEvaluate for asymmetric breath sounds• Consider tension pneumothorax if there is Consider tension pneumothorax if there is evidence of tracheal deviationevidence of tracheal deviation





Initial Management

Circulation:Circulation:• Active bleeding should be addressed Active bleeding should be addressed immediately by direct point pressureimmediately by direct point pressure

• Do not clamp bleeding vessels because Do not clamp bleeding vessels because you could cause further ischemiayou could cause further ischemia

• Avoid placing IV access where the flow Avoid placing IV access where the flow would head towards the injured area.would head towards the injured area.

Extravasation could create more distortion Extravasation could create more distortion and compressionand compression





Initial Management

DisabilityDisability• Examine and inspect for evidence Examine and inspect for evidence of focal neurological deficitof focal neurological deficit

• This could suggest direct nerve This could suggest direct nerve injury, or spinal cord injury or injury, or spinal cord injury or vascular injury leading to vascular injury leading to ischemiaischemia





Penetrating Injury

There are several mechanisms for There are several mechanisms for this penetrating injuries to the this penetrating injuries to the neck:neck:• KnivesKnives• Gunshot wounds Gunshot wounds • Sharp implementsSharp implements

All these mechanisms have the All these mechanisms have the potential for severe injurypotential for severe injury

Knives and guns make up nearly 95% Knives and guns make up nearly 95% of all these penetrating injuries.of all these penetrating injuries.





Penetrating Injuries

Due to higher kinetic energy, Due to higher kinetic energy, patients suffering from gunshot patients suffering from gunshot wounds suffer more damage than wounds suffer more damage than knife woundsknife wounds• Bullets have a tendency to penetrate Bullets have a tendency to penetrate deeper and create a cavitydeeper and create a cavity

• Secondary damage to tissues surrounding Secondary damage to tissues surrounding the actual track of the woundthe actual track of the wound

• Gunshot wounds to the lateral neck can Gunshot wounds to the lateral neck can cross the midline and create more cross the midline and create more damagedamage





Penetrating Injuries

Despite the different mechanisms, Despite the different mechanisms, basic treatment principals are the basic treatment principals are the samesame

Once initial stabilization has Once initial stabilization has occurred the wound itself should be occurred the wound itself should be evaluated.evaluated.

If the platysma has been disrupted If the platysma has been disrupted then it MUST be assumed that a then it MUST be assumed that a significant injury has occurredsignificant injury has occurred





Penetrating Injury

If the platysma is intact then local If the platysma is intact then local wound repair treatment of choicewound repair treatment of choice

Neck wounds must never be probed Neck wounds must never be probed beneath the platysmabeneath the platysma

Probing a deep neck wound could lead Probing a deep neck wound could lead to disruption of hemostatic plugto disruption of hemostatic plug

After determination of platysma After determination of platysma violation, track of the wound and violation, track of the wound and damaged structures must be evaluateddamaged structures must be evaluated





Penetration Injury

Once the wound location has Once the wound location has been found, you can generate a been found, you can generate a differential of potentially differential of potentially injured structures based on injured structures based on zone of injuryzone of injury

If the platysma has been If the platysma has been violated then a surgical violated then a surgical consultation should be obtainedconsultation should be obtained





Penetrating Injury

Diagnosis and ManagementDiagnosis and Management• Patients who are hemodynamically Patients who are hemodynamically unstable or have obvious deep unstable or have obvious deep injury require immediate surgical injury require immediate surgical attention (Operating Room)attention (Operating Room)

• Patients with normal vital signs Patients with normal vital signs will undergo further evaluation will undergo further evaluation depending on the zones that appear depending on the zones that appear to have been violatedto have been violated





Penetrating Injury

Diagnosis and Management:Diagnosis and Management:• In Zones I and III non-operative In Zones I and III non-operative studies are used to identify injuriesstudies are used to identify injuries

• Zone I injuries often will require a Zone I injuries often will require a thoracic surgeon to gain proximal thoracic surgeon to gain proximal vascular controlvascular control

• In zone III, attempts for distal In zone III, attempts for distal control , may require mandibular control , may require mandibular dislocation.dislocation.

• Given these difficulties, routine Given these difficulties, routine exploration is not recommendedexploration is not recommended





Penetrating Injury

No true consensus regarding No true consensus regarding management of zone II injuriesmanagement of zone II injuries

Current literature supports both Current literature supports both operative and non operative operative and non operative approaches to injuries deeper approaches to injuries deeper than the platysmathan the platysma

No clear evidence to support one No clear evidence to support one treatment modality over the othertreatment modality over the other





Zone II Injury

Operative management of GSW to carotid artery

Trauma.org



Diagnostic Tools

Vascular Evaluation = AngiographyVascular Evaluation = Angiography• Gold StandardGold Standard• Duplex ultrasound has recently gained Duplex ultrasound has recently gained prominence as less invasive toolprominence as less invasive tool

Esophageal EvaluationEsophageal Evaluation• EsophogramEsophogram• Performed for all Zone I/II InjuriesPerformed for all Zone I/II Injuries

Laryngotracheal Evaluation = Laryngotracheal Evaluation = BronchoscopyBronchoscopy• For all Zone I and II injuriesFor all Zone I and II injuries





Angiogram – GSW to Carotid Artery

Trauma.org



Penetrating Neck Injury Management

In summary for penetrating traumaIn summary for penetrating trauma• All hemodynamically unstable patients All hemodynamically unstable patients need surgical exploration immediatelyneed surgical exploration immediately

• Hemodynamically stable:Hemodynamically stable: Zone 1: Zone 1:

• Angiography Angiography • Esophogram/Endoscopy Esophogram/Endoscopy • Consideration for BronchoscopyConsideration for Bronchoscopy

Zone 2: Zone 2: • Same as above or Mandatory exploration by Same as above or Mandatory exploration by surgeonsurgeon

Zone 3: Zone 3: • AngiographyAngiography



Pediatric Considerations

The initial management steps are The initial management steps are the same as for the adult patientthe same as for the adult patient

The diagnostic process may be The diagnostic process may be associated with more morbidity as associated with more morbidity as most children will require most children will require anesthesia to obtain studiesanesthesia to obtain studies

Zone 2 injuries with stable vital Zone 2 injuries with stable vital signs are often observed closelysigns are often observed closely





Blunt Neck Trauma

Blunt trauma to the neck is Blunt trauma to the neck is less frequent in occurrenceless frequent in occurrence

Mechanism is often related to Mechanism is often related to motor vehicle collisionsmotor vehicle collisions• HyperextensionHyperextension• RotationRotation• Hyper flexionHyper flexion• Direct blows against a non mobile Direct blows against a non mobile object (most commonly seatbelts)object (most commonly seatbelts)





Blunt Trauma

Other mechanisms include:Other mechanisms include:• Direct blows during sports Direct blows during sports

E.g. Fists, elbows, fast moving soccer E.g. Fists, elbows, fast moving soccer balls, hockey pucksballs, hockey pucks

• Handle bars from bicyclesHandle bars from bicycles• StrangulationStrangulation

Often, less Often, less ““excitingexciting”” on on presentation but these injuries presentation but these injuries can be lethal or life threateningcan be lethal or life threatening





Blunt Trauma

Signs and symptoms of significant Signs and symptoms of significant injury are often delayedinjury are often delayed

If a significant mechanism for If a significant mechanism for injury exists, then the patient injury exists, then the patient should be closely observed for should be closely observed for deteriorationdeterioration

If significant mechanism exists, If significant mechanism exists, surgical consultation should be surgical consultation should be obtained early in evaluation periodobtained early in evaluation period





Laryngotracheal Injury

Following blunt neck trauma, Following blunt neck trauma, Laryngotracheal injury should be Laryngotracheal injury should be ruled outruled out

These injuries can range from soft These injuries can range from soft tissue swelling to bruising and tissue swelling to bruising and vocal cord avulsions.vocal cord avulsions.• Fractures of the hyoid or cricoid Fractures of the hyoid or cricoid cartilagecartilage

• Nerve damage: recurrent laryngeal nerveNerve damage: recurrent laryngeal nerve• Disruption of the larynx or tracheaDisruption of the larynx or trachea






Signs and symptoms:Signs and symptoms:• Difficulty swallowing Difficulty swallowing • Pain with swallowingPain with swallowing• Difficulty breathing (feeling Difficulty breathing (feeling breathless)breathless)

• Hoarseness of voice (or change in Hoarseness of voice (or change in voice)voice)

• Subcutaneous emphysemaSubcutaneous emphysema• Tracheal deviationTracheal deviation

However signs and symptoms may be However signs and symptoms may be absent even with a major injuryabsent even with a major injury





Laryngotracheal Injury Blunt trauma to neck with swelling and subcutaneous emphysema

http://www.ispub.com/ispub/ijorl/volume_9_number_1_10/extensive_laryngotracheal_trauma/trauma-fig1.jpg




Management:Management:• High index of suspicion is required to High index of suspicion is required to diagnose these types of injuries diagnose these types of injuries especially in the absence of classic especially in the absence of classic symptomssymptoms

• Securing an airway is the initial focus.Securing an airway is the initial focus. Endotracheal intubation should be attempted Endotracheal intubation should be attempted by the most experienced personby the most experienced person

Other authors suggest immediate tracheostomy Other authors suggest immediate tracheostomy to avoid creating a false path or further to avoid creating a false path or further injury to the unstable airwayinjury to the unstable airway

Cricothyrodotomy should be avoided as this Cricothyrodotomy should be avoided as this may worsen the injurymay worsen the injury




Management (continued):Management (continued):• After securing a definitive After securing a definitive airway:airway:

X-rays to evaluated for free airX-rays to evaluated for free air CT scan to evaluate for bony injury CT scan to evaluate for bony injury and to further define the type and and to further define the type and degree of tracheal injurydegree of tracheal injury

Laryngosocopy/Bronchoscopy to Laryngosocopy/Bronchoscopy to evaluate vocal cordsevaluate vocal cords





Vascular Injury

Vascular Injuries may be Vascular Injuries may be delayed in presentationdelayed in presentation

Symptoms are often attributed Symptoms are often attributed to concurrent head injuryto concurrent head injury

Any mechanism that stretches or Any mechanism that stretches or compresses the artery can lead compresses the artery can lead to injuryto injury





Vascular Injury 5 injury mechanisms described:5 injury mechanisms described:

• HyperflexionHyperflexion Compression of artery between the Compression of artery between the spine and mandiblespine and mandible

• HyperextensionHyperextension Compression of artery against the Compression of artery against the transverse process of spinetransverse process of spine

• Direct contact with forceDirect contact with force• Basilar skull fracture with injury Basilar skull fracture with injury to distal portion of carotid arteryto distal portion of carotid artery

• Intra-oral traumaIntra-oral traumaGhana Emergency Medicine




Strangulation

Strangulation injuries are the Strangulation injuries are the result of significant result of significant application of pressure to the application of pressure to the neckneck

Mechanism of strangulation Mechanism of strangulation injuries:injuries:• HangingHanging• Cord strangulationCord strangulation• Manual strangulationManual strangulation





Strangulation

PathophysiologyPathophysiology• Compression results in spinal cord Compression results in spinal cord and brainstem injuryand brainstem injury

• Compressive forces can lead to Compressive forces can lead to cerebral ischemia and then deathcerebral ischemia and then death

• Compression also can cause Compression also can cause mechanical airway obstructionmechanical airway obstruction

• Bony fractures: Often associated Bony fractures: Often associated with edemawith edema

Hyoid, cricoid and larynx Hyoid, cricoid and larynx Ghana Emergency Medicine




Strangulation vs. Judicial Hanging

Geerto (Wikipedia) http://3.bp.blogspot.com/_at3Zkq7CIMs/SUmf3jf5rGI/AAAAAAAABAo/MHPgOpUUmIE/s400/Hanging.jpg



Evaluation and treatment:Evaluation and treatment:• Airway – First priorityAirway – First priority• Breathing (respiratory mechanism)Breathing (respiratory mechanism)

Evaluate for evidence of pulmonary edemaEvaluate for evidence of pulmonary edema

• Circulation Circulation Evaluate for cardiac arrhythmiaEvaluate for cardiac arrhythmia Treat hypotensionTreat hypotension

• Neurological complicationsNeurological complications Secondary to ischemia and or hypoxiaSecondary to ischemia and or hypoxia

C-spine fracture should be suspected C-spine fracture should be suspected if hanging from a height greater than if hanging from a height greater than patients heightpatients height



Strangulation





Questions?

Dkscully (flickr)



References Baron, B. J. (2006). Penetrating and Blunt Neck Baron, B. J. (2006). Penetrating and Blunt Neck Trauma. In J. Tintanalli, Trauma. In J. Tintanalli, Emergency Medicine a Emergency Medicine a Comprehensive guideComprehensive guide (pp. 1590-1596). Chicago: (pp. 1590-1596). Chicago: McGraw-Hill.McGraw-Hill.

Buechter, K. S. (2008, February 16). Buechter, K. S. (2008, February 16). Penetrating Penetrating Neck InjuriesNeck Injuries. Retrieved september 25th, 2009, from . Retrieved september 25th, 2009, from Medscape: Medscape: http://www.medscape.com/viewarticle/410560_3http://www.medscape.com/viewarticle/410560_3

Levy, D. B. (2008, December 12). Levy, D. B. (2008, December 12). Neck TraumaNeck Trauma. . Retrieved September 20, 2009, from Emedicine: Retrieved September 20, 2009, from Emedicine: http://emedicine.medscape.com/article/827223-http://emedicine.medscape.com/article/827223-overviewoverview

Newton, k. (2002). Neck. In J. A. Marx, Newton, k. (2002). Neck. In J. A. Marx, Rosen's Rosen's Emergency MedicineEmergency Medicine (pp. 370-380). St Louis: Mosby. (pp. 370-380). St Louis: Mosby.

author(s): patrick carter, daniel wachter, rockefeller oteng, carl seger, 2009-2010. license: unless...

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