vascular neck trauma
DESCRIPTION
TRANSCRIPT
VASCULAR NECK TRAUMA
Case 1
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
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
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
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
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)
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
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
Imaging
Imaging report
2x metallic foreign bodies- one at level of C2, one embedded in SCM
6mm ECA pseudoaneurysm 2.5cm above angle of mandible
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
Case 2
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
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
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
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
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
Management
6L O2 via Hudson Mask 2x large bore cannulae, IV Hartmann’s
solution IV cephazolin, ADT NBM CT angiogram of head & neck performed
Imaging
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
Further Management
HDU admission for airway, circulation observations
For exploration of neck wound with ASU and vascular team early the next day
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
Further Progress
Returned to HDU postoperatively for airway & circulatory monitoring
No immediate postoperative complications
Discharged the next day on oral antibiotics
25% of head/neck trauma5-10% all arterial injuryCarotid injury- 10-30% mortality; 15-60% permanent neurologic deficit
Vascular Neck Injuries
Relevant Anatomy
Subcl aa & vvJugular vvCCATracheaOesophagus, thyroid
CCAICA, ECAJugular vvLarynxHypopharynxCr X, XI, XII
ICA, ECAJugular vvLat pharynxCr VII, IX, X, XI, XII
Relevant Anatomy (cont.)
Relevant Anatomy (cont.)
Vascular traumatic injuries
Complete or partial transection Intimal flap/dissection Aneurysm Pseudoaneurysm Fistula Extrinsic compression Thromboembolism as a result of intimal
injury
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
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
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)
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
Iatrogenic injury
CVC insertion Cerebral Angiography C-spine surgery, transsphenoidal, skull
base surgery Radiotherapy (stenosis) Nerve blocks (vertebral aa injury)
Comorbid injuries
Airway – pharynx, larynx, trachea Pneumothorax, haemothorax (Zone 1) Nerve injuries
Cranial VII, IX, X, XI, XII Brachial plexus Cervical sympathetic chain (Horner’s)
C-spine, mandibular, temporal fractures Oesophagus Parotid, salivary glands, lymph nodes Thyroid (Zone 1)
Emergent Resuscitation
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
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 assoc haemo/pneumothorax Index of suspicion for aspiration
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
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
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
Disability
If suspicion of C-spine injury- hard collar Focal neurology in stroke territory
should alert to possible vasc injury Cranial nerve VII --> XII (except VIII) Horner’s syndrome (compression of cervical
chain) Brachial plexus injury
Other Injuries on Secondary Survey Aerodigestive – oesophagus & pharynx
Drooling Odynophagia, dysphagia
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
Investigation
Bloods
Hb, haematocrit (blood gas or formal) BSL- must optimise O2 & glucose
delivery ABG in airway/breathing compromise
Plain radiography
CXR & neck XR Foreign bodies Injury to lung apices- haemo/pneumothorax Mediastinal widening Surgical emphysema, aerodigestive injuries (C-spine fractures)
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
Endovascular, operative, supportive
Management
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
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
Indications for urgent surgery Airway compromise Haemodynamic instability Active pulsatile haemorrhage Expanding haematoma
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
Indications for angiography +/- endovascular intervention
Assessment of zone 1 & zone 3 injuries unable to be visualised otherwise
Embolisation of persistent ECA bleeding Embolisation of osseus verterbal 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
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