null.pptxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Neck trauma

1. NECK TRAUMA P R E S E N T ER : D R . O J A N GOLE ALBERT S U P ERVISOR : D R . MUGYENYI / D R . F I S T O N / D R . B I T A M A Z I R E

2. Outline Epidemiology Clinical anatomy Neck trauma by zone: I, II, III Neck trauma by mechanism Penetrating trauma Blunt trauma Upper cervical spine injuries Reference

3. Epidemiology 3500 deaths per year Mortality rate 2-6% Blunt mechanism accounts for 5% Penetrating trauma accounts for most Zone I injuries are the most lethal Airway occlusion and hemorrhage are the most immediate threats to life .

4. Epidemiology Commonly injured vessels Internal jugular vein Internal carotid artery Laryngeal and tracheal more common than pharyngeal and esophageal injuries

5. Clinical anatomy Is complex in a small area: aerodigestive and neurovascular structures confined It contains: Superficial fascia: the platysma Deep cervical fascia : investing , pretracheal , & prevertebral layers Carotid sheath: carotid artery, IJV,vagus nerve Prevertebral fascia pouch: axillary sheath

6. Neck Triangles Anterior Triangle: bounded by anterior border of the sternocleidomastoid, anterior midline of the neck , inferior border of the mandible. Posterior Triangle: bounded by posterior border of the sternocleidomastoid muscle, anterior border of the trapezius muscle, superior border of the clavicle.

7. Neck triangle

8. Anatomical Review

9. Neck zones Three zones: Zone I - Clavicles and sternal notch to cricoid cartilage Zone II – Cricoid cartilage to the angle of mandible Zone III – Angle of mandible to base of skull III II I

10. Neck zones

11. Neck trauma by zone

12. Zone I Subclavian vessels Brachiocephalic veins Common carotid arteries Aortic arch Jugular veins Esophagus Lung apices C- spine/cord Cranial nerve roots

13. Zone II Carotid and vertebral arteries Jugular veins Pharynx Larynx Trachea Esophagus C-spine/cord

14. Zone III Salivary and parotid glands Esophagus Trachea Vertebral bodies Carotid arteries Jugular veins Cranial Nerves IX-XII

15. Neck trauma by mechanism

16. Structures at Risk Musculoskeletal Vertebral bodies Cervical muscles and tendons Clavicles, 1 st and 2 nd ribs Hyoid bone Glandular Thyroid Parathyroid Submandibular Parotid glands

17. Structures at Risk Visceral structures Thoracic duct Esophagus Pharynx Larynx Trachea

18. Structures at Risk

19. Structures at Risk

20. Types of neck trauma According to mechanism: Penetrating trauma Blunt trauma

21. PENETRATING NECK TRAUMA

22. Mechanisms Mechanisms Knives, glass,… Single Projectiles: Handguns, Rifles Multiple Projectiles Shotgun pellets Improvised explosive devices (IEDs) Grenades Rocket

23. Key Findings Hard signs Airway obstruction Pulsatile bleeding Expanding hematoma Unresponsive to resuscitation Extensive subcutaneous emphysema Soft signs Voice change Wide mediastinum Hemoptysis Hematemesis Dysphonia/dysphagia

24. Control Bleeding Local pressure only No tourniquets No pressure dressings No probing or blind clamp placement http://chestofbooks.com

25. Management - Primary Survey ATLS: ABCs Ensure airway is patent Ensure patient is adequately oxygenating Control any obvious hemorrhaging IV access

26. Airway Considerations Who requires immediate intubation? Apneic Comatose Respiratory compromise Expanding neck hematoma Massive subcutaneous emphysema Massive bleeding in airway

27. Airway Considerations “Wait and See” Avoid excessive bag-valve-mask Exercise caution with paralytics and sedation Surgical airway last resort Cricothyrotomy vs. tracheostomy

28. Physical Exam Violation of the platysma muscle CNS exam Obvious hematoma, bleeding

29. Physical exam Contusions, lacerations, abrasions to the neck, etc. Expanding hematomas, obvious bleeding Hoarseness, stridor, Subcutaneous emphysema Hemoptysis, drooling Dyspnea Distortion of the normal anatomic landmarks Mandibular/midface instability

30. Diagnostic Studies Chest radiograph CT and CT angiogram Laryngeal injury Tracheal injury Vessels Blunt esophageal injury

31. Diagnostic Studies CT S can Can aid in identifying weapon trajectory and structures at risk Should only be used in stable patients Gracias et al (2001) found that use of CT scan in stable patients Saved patients from arteriogram indicated by older protocols 50% of the time Avoided esophagoscopy in 90% of patients who might otherwise have undergone it

32. Diagnostic Studies Laryngoscopy Bronchoscopy Esophagoscopy; esophagram Rigid vs. flexible esophagoscopy Color flow doppler, duplex ultrasonography MRA

33. Diagnostic Studies Arteriogram Gold standard Invasive C omplications Availability varies Expensive Contrast load Simultaneous intervention

34. Specific Injuries Vascular Aerodigestive Cranial nerves Thoracic duct

35. Vascular Injuries in the Neck Physical Exam External marks Decreased LOC Hemiparesis Hematoma Hypotension Dyspnea Thrill, bruit, pulse not present

36. Associated Injuries Le Fort II or III fractures Basilar skull fracture involving the carotid canal Diffuse Axonal Injury with GCS < 6 Cervical vertebral body fracture Near hanging with anoxic brain injury Seatbelt abrasion of anterior neck with significant swelling/altered mental status

37. Primary Diagnostics CT angiogram of the neck Chest x-ray indicated in Zone I injuries because of their proximity to the chest Complete blood count, basic metabolic panel, toxicology and blood alcohol content

38. Primary Diagnostics

39. Vascular Injury Management Common carotid: repair preferred over ligation in almost all cases Internal carotid: Shunting is usually necessary Vertebral: Angiographic embolization or proximal ligation can be used if the contralateral vertebral artery is intact Internal Jugular: Repair vs. ligation

40. Carotid Artery Interposition Repair

41. Pharynx and esophageal injury Clinical sign and symptom  neck exploration Subcutaneous emphysema Hematemesis > 50%of Pt.  asymptomatic at presentation Combination of esophagoscopy and contrast esophagography Most sensitive for detected injury Delayed repair beyond 24 hrs after injury  poorer outcome

42. Digestive tract evaluation Esophageal perforation  gastrografin swallow Barium : extravasation & distort soft tissue plane and toxic Flexible esophagoscopy Combination of flexible and rigid endoscopy Suspicious pharyngeal perforation NPO for several days S&S : fever , tachycardia,widening of mediastinum Repeat endoscopy or neck exploration Investigation

43. Treatment Treatment Conservative: Medical therapy Adequate ventilation & oxygenation Fluid resuscitation Monitor neurolodic status Pain control ABO Tetanus prophylaxis Treatment Surgical approach Zone 1  Median sternotomy or Thoracotomy Zone 2  Collar incision or Apron incision Zone 3  Consult neuroSx

44. BLUNT TRAUMA

45. Blunt Trauma Uncommon overall; 0.08–1.5 % Direct trauma or hyperextension RTAs, remain the most common etiology Injury: laryngeal , vascular, and digestive easily O ccult cervical spine injury

46. Mechanism M otor vehicle/bikes accidents/crush injuries rapid acceleration & deceleration direct blow of the anterior neck Raised intrathoracic pressure against a closed glottis Strangulation hanging, ligature suffocation, manual choking Clothesline injuries in sports ( rugby,football tackle, martial arts), all-terrain vehicles, motorcycles,snowmobiles . Direct blows fists, feet, and other blunt weapons Excessive cervical manipulation

47. Management Need careful observation : delayed onset S low progression of airway edema airway obstruction may not occur until several hours after the injur CT may be helpful to determine degrees of injury to the larynx and vessels Blunt injury to the cervical vessels can lead to thrombosis , intimal tears, dissection, and pseudoaneurysm

48. Treatment Vx are the commonest to be injured T3 options for blunt artery injuries are based on the mechanism, type of injury, and location Treatments for blunt artery injuries include surgery, anticoagulation, and observation. Surgical intervention for blunt vascular injuries includes ligation, resection, thrombectomy , and stent placement

49. Upper cervical spine injuries

50. Upper cervical spine injuries Craniocervical dislocation This injury is usually caused by high energy trauma and is often fatal. The dislocation may be anterior, posterior or vertical.

51. This is uncommon and either resolves spontaneously or with traction. Isolated , traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion. Atlanto axial instability

52. Jefferson fractures (C1 ring ) These injuries are associated with axial loading of the cervical spine Associated transverse ligament rupture may occur. Most are treated non-operatively in a collar or halo brace.

53. Odontoid fractures There are three types of Odontoid peg fracture. Neurological injury is rare. The majority of acute injuries are treated non-operatively in a halo jacket or hard collar for three months. Internal fixation with an anterior compression screw is indicated in displaced fractures. Posterior C1/2 fusion is required in cases of non-union.

54. . .

55. Hangman’s fracture I s a traumatic spondylolisthesis of C2 on C3. There are four types with varying degrees of instability. Those with significant displacement or associated facet dislocation are treated operatively, usually with posterior stabilization.

56. REFERENCES Schwartz’s Principles of Surgery 11 th edition , New York Chicago by Charles Brunicardi , MD, FACS. BRS gross anatomy 7th edition , Philadelphia by Kyung Won Chung. Bailey and Love's Short Practice of Surgery;  27th edition. Edited ATLS - ADVANCED TRAUMA LIFE SUPPORT 2020 - American College of Surgeons, Committee on Trauma - Chicago, Ill. In-text : (ATLS - Advanced trauma life support, 2020) Up to date 2020

57. THANKS .