Surgical_Anatomy_of_Neck_and_Trauma_Management.pptx

Surgical anatomy of neck and trauma management

1. Surgical Anatomy Of Neck And Management Of Neck Trauma Dr Sandeep JR,GS

2. CONTENT SURGICAL ANATOMY OF NECK FASCIA AND SPACES TRIANGLES AND CONTENTS ZONES AND CONTENTS NECK TRAUMA AND MANAGEMENT ETIOLOGY PENETRATING TRAUMA NECK AND MANAGEMENT BLUNT TRAUMA NECK AND MANAGEMENT

3. SURGICAL ANATOMY OF NECK NECK FASCIA AND SPACES NECK FASCIA Superficial fascia Deep fascia Deep investing Pretracheal prevertebral

4. DEEP NECK SPACES Infrahyoid spaces visceral carotid Perivertebral Retropharyngeal Danger suprahyoid spaces Pharyngomuscula Masticator Parotid parapharyngeal carotid Perivertebral Retropharyngeal Danger

5. TRIANGLES OF NECK

6. POSTERIOR TRIANGLE CONTENTS: Arteries : 3rd part of subclavian artery, Transverse cervical artery, Suprascapular artery Veins : External jugular vein, Subclavian vein Nerve elements: Spinal root of accessory nerve, Trunks of brachial plexus, Branches of cervical plexus

7. ANTERIOR TRIANGLES

8. SUBMANDIBULAR TRIANGLE Contents: •Submandibular salivary gland. •Submandibular lymph nodes. •Facial artery. •Facial vein.

9. CAROTID TRIANGLE Contents of carotid triangle: Arteries: a) Common carotid artery b) Internal carotid artery c) External carotid artery and 5 of its branches (facial– lingual– superior thyroid- occipital &ascending pharyngeal). Veins: Internal jugular vein. Nerves : Vagus Nerve Hypoglossal nerve

10. Zones of the Neck in Trauma Zone-1 Zone-3 Zone-2

11. PENETRATING NECK TRAUMA Incidence : 5-10% Mortality : 10% (gun shot> stab) Early: vascular injury late: esophageal injury Components of injury : vascular> laryngo-tracheal >pharyngo- esophageal NECK TRAUMA MECHANISM OF NECK TRAUMA PENETRATING NECK TRAUMA BLUNT NECK TRAUMA STRANGULATION AND NEAR HANGING

12. GENERAL RULES: Impaled objects should not be removed Cervical spine immobilization is not routinely recommended in all penetrating neck injuries. (Indication -Suspicion based on CCR and NEXUS clinical screening tools) Avoid blind procedures: a) intubation b) NG placement c) probing to wound, and no ligation /clamping of the vessels in E.D. 4. Never place an intravenous line in the arm on the same side as a supraclavicular injury, because of the possibility of a subclavian vessel injury. 5. Air embolism- prevention by Trendelenburg position and occluding the wound with gauze.

13. MANAGEMENT OF NECK TRAUMA AIRWAY AND C-SPINE- DEFINITE AIRWAY (CRICOTHYROIDOTOMY > TRACHEOSTOMY) BREATHING CIRCULATION AND HEMORRGIC CONTROL (FOLLEYS , OPPOSITE SIDE IV CANNULATION) DISABILITY EXPOSURE AND ENVIRONMENT (RISK OF AIREMOBILISM –TRENDELENBURG , OCCLUDE THE WOUND )

14. Patients with hard signs of- vascular injury Pulsatile bleeding large or expanding hematoma bruit or thrill shock A erodigestive tract injury massive hemoptysis massive Hematemesis air bubbling from a wound

15. PENETRATING NECK TRAUMA

16. No zone approach The location of the external wound is not a guarantee that all of the underlying injured structures will remain within that zone.

17. SURGICAL STEPS POSITIONING & SKIN PREPARATION INCISIONS EXPOSURE MANAGEMENT OF INJURED STRUCTRES

18. POSITIONING & SKIN PREPARATION SUPINE WITH ARMS ABDUCTED HEAD AND NECK EXTENSION * HEAD TURNED TO OPPOSITE SIDE** SKIN PREP- EAR TO EAR- CHIN –ABDOMEN WITH B/L AXILLA . BOTH GROIN*

19. INCISIONS ANTERIOR SCM INCISION COLLOR INCISION CLAVICULAR INCISION STERNOTOMY INCISION TRAP-DOOR

20. EXPOSURE SKIN-SUBCUTANEOUS TISSUE-PLATYSMA CAROTID ARTERIES AND IJV SCM-RETRACT LATERALLY CAROTID SHEATH-OPEN VERTIBRAL ARTERY SCM-RETRACT LATERALLY CAROTID SHEATH-RETRACT MEDIALLY AERODIGESTIVE TRACT SCM-RETRACT LATERALLY CAROTID SHEATH-RETRACT LATERALLY Subclavian vessels Right –median sternotomy Left-high anterolateral thoracotomy +clavicular resection

21. A) Carotid Artery and Internal Jugular Vein Injuries

22. SURGICAL MANAGEMENT OF INJURED STRUCTRES IJV and Subclavian vein “Extensive vein repair don’t have role in penetrating neck injuries when time is critical” Carotid arteries Ligation(ICA-45% mortality) Repair/reconstruction Temporary shunting Vertebral arteries Challenging Safe procedure-V1 ligation f/b postop embolisation of distal segment (V2/V3) Subclavian artery Ligation Repair/reconstruction

23. SURGICAL MANAGEMENT OF INJURED STRUCTRES Trachea Primary repair R/A PUT A TRACHEOSTOMY TUBE IN DEFECT Esophagus PRIMARY REPAIR (2 LAYERS> 1 LAYER) CERVICAL ESOPHAGOSTOMY Esophageal repair should be drain away from vascular repair and a muscle pedicle cover should be placed at b/w two repairs

24. Blunt trauma neck

25. The Denver screening criteria for blunt cerebrovascular injury Any cervical spine fracture Unexplained neurological deficit incongruous with imaging Basilar cranial fracture into carotid canal Le Fort II or III fracture Cervical hematoma Horner syndrome Cervical bruit Ischemic stroke Head injury with Glasgow Coma Scale score ＜6 Hanging with anoxic injury

26. Denver radiological grading scale of blunt cerebrovascular injury Denver radiological grading scale CHARACTERISCTICS Grade I Irregularity of vessel wall or dissection/intramural hematoma with ＜25% stenosis Grade II Intramural thrombus or raised intimal flap or dissection/intramural hematoma with ＞25% stenosis Grade III Pseudoaneurysm Grade IV Vessel occlusion Grade V Vessel transection

27. BLUNT TRAUMA NECK

28. Knowing the contents of each zone is important when considering possible injuries. • Zone1:themajor vessels of the upper mediastinum, the lung apices, esophagus , trachea, thoracic duct, and thyroid gland. • Zone 2: the carotid sheath and contents, vertebral arteries, esophagus , trachea, pharynx, and the recurrent laryngeal nerve. • Zone 3: distal carotid and vertebral arteries, distal jugular veins

29. Complications in Neck Trauma • Airway obstruction, vascular injury, nerve damage. • Risk of infection, mediastinitis, and other complications.

30. Conclusion • Understanding surgical anatomy is vital for managing neck trauma effectively. • Early assessment, appropriate imaging, and timely interventions can save lives.