Penetrating Neck Trauma

Penetrating Neck
Trauma
Diane M. Birnbaumer, M.D., FACEP
Professor of Clinical Medicine
David Geffen School of Medicine at UCLA
Senior Physician
Department of Emergency Medicine
Harbor-UCLA Medical Center
What IS Penetrating Neck
Trauma?
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Injuries from GSW, stabbing, penetrating
debris
Violates the platysma
Often injures multiple structures
Mortality highly variable: 2-65%
Prehospital Management
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Cervical spine immobilization?
Airway management?
Venous access?
Prehospital Management
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Cervical spine immobilization? Of course!
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Or maybe not…
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Less than 0.5% of patients with penetrating wounds to
the neck have an unstable cervical spine injury
All of them tend to have signs or symptoms of
neurologic impairment or altered mental status, so…
If altered, immobilize
If neuro findings, immobilize
Prehospital Management
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Airway management?
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Oxygen; suction as needed
Position of comfort if possible
Assist, intubate as needed
Venous access?
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On opposite side of injury, if possible
Assessment of the Patient
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Where is the injury?
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Anterior or posterior?
Deep to the platysma?
Which zone(s) is (are) involved?
Anterior or Posterior?
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Most
important
structures are
in the anterior
triangle
Posterior:
Spinal cord
Anatomy of the Neck: Triangles
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Anterior Triangle
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Midline anteriorly
Sternocleidomastoid
posteriorly
Clavicle inferiorly
Mandible superiorly
Posterior Triangle
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Sternocleidomastoid
anteriorly
Trapezius posteriorly
Clavicle inferiorly
The Platysma
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1
Is the injury
deep to the
platysma?
If not, just
close and go
Zones of the Neck
3
Anatomy of the Neck
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Zone I
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Zone II
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Between the sternal notch and clavicles inferiorly and the
cricoid cartilage superiorly
Between the cricoid cartilage inferiorly and the angle of the
mandible superiorly
Zone III
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Between the angle of the mandible inferiorly and the base of
the skull superiorly
Zone I Contains:
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Common carotid artery
Vertebral artery
Subclavian artery
Major vessels of the
upper mediastinum
Apices of lungs
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Esophagus
Trachea
Thyroid
Thoracic duct
Spinal cord
Zone II Contains:
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Common carotid artery
Vertebral artery
Larynx
Trachea
Esophagus
Pharynx
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Internal jugular vein
Vagus nerve
Recurrent laryngeal
nerve
Sympathetic trunk
Spinal cord
Zone III contains:
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Internal and external
carotid arteries
Vertebral arteries
Jugular veins
Salivary and parotid glands
Cranial nerves IX-XII
Spinal cord
Floor of mouth / skull
Penetrating injuries broken
down by zone
Gracias
2001
Osborn
2008
Thoma
2008
Bagheri
2008
Brennen
2010
Zone I
20%
14%
16%
15%
Zone II
77%
36%
64%
85%
25%
18%
20%
8%
Zone III
Post Triangle
39%
42%
What gets injured?
Location
Study 1 (1275)
Study 2
Thoma
Arterial
320 (25%)
12.8%
Venous
281 (22%)
11.3%
Tracheolaryngeal
253 (20%)
10.1%
3.9%
Pharyngoesophageal
240 (19%)
9.6%
8.8%
Spinal cord
76 (6%)
3%
0.5%
Neurologic, other
85 (7%)
3.4%
Thoracic duct
20 (2%)
0%
13.3%
Assessment of the Patient
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Where is the injury?
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Anterior or posterior?
Deep to the platysma?
Which zone(s) is (are) involved?
Is the patient stable or unstable?
Are there any “hard findings” on exam?
Signs of injury: Examine for These
Hard Signs
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Soft Signs
 Hemoptysis/hematemesis
Expanding Hematoma
 Oropharyngeal blood
Severe active bleeding
Shock not responsive to IVF  Dyspnea
 Dysphonia/dysphagia
Decreased/absent radial
pulse
 Subcutaneous/mediastinal air
Vascular bruit or thrill
 Chest tube air leak
Cerebral ischemia
 Non-expanding hematoma
Airway obstruction
 Focal neurologic deficit
Initial Management
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Venous access; opposite side of injury
Oxygen; airway management as needed*
Bleeding profusely? Pressure; do not clamp
structures
Airway Management
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What are the issues?
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Potential to lose the airway if injury worsens
Potential to worsen the injury by patient
coughing, worsening bleeding, direct trauma
Penetrating Neck Injury
Airway Management
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Immediate airway management
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Decreasing mental status
Expanding hematoma
Direct laryngotracheal trauma
Hypoventilation
Hypoxia
Selective intubation
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Ah… here’s where the rubber meets the road
Penetrating Neck Injury
Airway Management
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Selective airway management
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Consider in any patient leaving the ED for a study or
transportation
Consider in any patient who may develop airway
compromise
Okay, that sounds good, but…
How to do it????
Penetrating Neck Injury
Airway Management
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What are your options?
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RSI with orotracheal intubation
Awake intubation
Fiberoptic
Videoscopic intubation
Extraglottic devices
Nasotracheal
Cricothyrotomy
Penetrating Neck Injury
Airway Management
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Airway Management
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RSI with direct laryngoscopy
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Fiberoptic intubation
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Most data available; usually a safe practice; have backup
airway available
Awake fiberoptic an option
May be difficult / impossible in a bloody airway
Videoscopic devices
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Little data published; success rates high
Airway Management
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Airway Management
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Extraglottic devices
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Nasotracheal intubation
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Run the risk of worsening injury, dislodging clot, requires
paralysis if patient awake
Relatively contraindicated due to blind procedure
Cricothyrotomy / tracheostomy may be necessary
Direct intubation
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Put the tube in the open wound, directly into the trachea
Penetrating Neck Trauma
Airway Management
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Mandavia, et al
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USC, 1993-1996
78% GSW, 21% SW
748 patients
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In 11%, airway emergently managed in ED
 RSI – 39
 Cricothyrotomy / tracheostomy - 2
 No drugs – 5
 Fiberoptic - 12
Penetrating Neck Trauma
The Traditional Approach
Emergent
Airway, then
OR
Wound Care,
Discharge
Zone I
Angiography,
Esophagoscopy,
Bronchoscopy
Observe
Platysma
Violation?
No
No
No
Yes
Patient
Stable?
Yes
Zone II
Yes
Symptomatic?
OR
Observe
No
Zone III
Yes
Symptomatic
Angiography
Imaging?
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What does the current literature say?
2001 Gracias et al.
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Retrospective case series of 68 patients, 23 of
which were included:
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13 patients were determined to have trajectories
with low likelihood of vascular or aerodigestive
injuries and managed non-operatively.
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4 were discharged from the ED
7 were discharged within 24 hours
2008 Osborn et al.
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Retrospective case series of 120 patients, 65 of
which were included:
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24 received a CTA, 6 got explored (25%)
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25% determined to have injury
0 negative explorations
41 received no CTA, 27 got explored (66%)
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34% determined to have injury
13 had negative explorations (48%) and 4 minor
superficial bleeding vessels
2008 Thoma et al.
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A prospective observational study of 203
patients with 159 stab wounds, 42 GSW’s, one
automobile part and one explosive shrapnel:
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25 were managed operatively
8 were managed endovascularly
158 received what the surgeon believed to be
appropriate imaging and work-up and were
managed expectantly
No clinically relevant missed injuries
Vick & Islam 2008
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Retrospective case series of 19,363 pediatric
trauma patients, including 39 children with 42
injuries violating the platysma:
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Six patients underwent mandatory exploration, four
were nontherapeutic;
Eighteen patients underwent imaging (68% CTA),
15 were observed and avoided surgical exploration.
EAST Clinical Practice Guideline
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Clinical Practice Guideline for Penetrating Zone II injuries:
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Selective operative management and mandatory surgical exploration
have equivalent diagnostic accuracy therefore selective management is
recommended to reduce unnecessary operations. (Level I)
High resolution CTA offers appropriate diagnostic accuracy with minimal
risk, making this the initial diagnostic study of choice when available.
(Level II)
CT angiography or duplex US can be used in lieu of arteriography to rule
out and arterial injury in penetrating injuries to zone II of the neck.
(Level II)
CT of the neck (even without CT angiography) can be used to rule out a
significant vascular injury if it demonstrates that the trajectory of the
penetrating object is remote from vital structures. With injuries in
proximity to vascular structures, minor vascular injuries such as intimal
flaps may be missed. (Level III)
Kesser 2009 et al.
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Invited Commentary
“The standard of care is no longer surgical
exploration for all penetrating neck trauma as
numerous studies have clearly demonstrated
that stable patients can be imaged and/or
observed.”
Imaging?
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Stable patients can be imaged and observed
Unstable patients need to go to the OR
Hard findings are critical in the diagnostic
algorithm
OR
Wound Care,
Discharge
OR
No
Platysma
Violation?
Obvious
Injury
Yes
Yes
Patient
Unstable or
Hard signs of
injury?
No
CTA Neck
No obvious injury
but trajectory
suggests possible
injury
Appropriate
imaging or
intervention
No obvious injury
and trajectory away
from vital structures
Observe/
Discharge
References/Images
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Bagheri SC, Khan A, Bell RB. Penetrating Neck Injuries. Oral and Maxillofacial Surgery Clinics of North America. August 2008;20(3):393-414.
Brennan J, Lopez M, Gibbons MD, et. al. Penetrating Neck Trauma in Operation Iraqi Freedom. Otolaryngology – Head and Neck Surgery. December
2011;144:180-185
Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of Penetrating Neck Injury in the Emergency Department: A Structued Literature Review.
Emergency Medicine Journal. 2008;25:711-715
Demetriades et al. “Complex Problems in Penetrating Neck Trauma.” Surgical Clinics of North America Vol 76;4. August 1996; 661-683
Gracias VH, Reilly PM, Philpott J, et. al. Computed Tomography in the Evaluation of Penetrating Neck Trauma: A Preliminary Study. Archives of Surgery.
November 2001;136:1231-1235
Jarvik et al. “Penetrating Neck Trauma: Sensitivity of Clinical Examination and Cost-effectiveness of Angiography.” AJNR Am J Neuroradiol 16;647-654.
April 1995
Kendall et al. “Penetrating Neck Trauma.” Emergency Medicine Clinics of North America. Vol 16;1. Feb 1998. 86-105
Kesser BW, Chance E, Kleiner D, Young JS. Contemporary Management of Penetrating Neck Trauma. The American Surgeon. January 2009;75:1-10
Levy, David and Brian Gruber. “Neck Trauma” emedicine. Dec 10,2009.
Lustenberger T, Talving P, Lam L. et. al. Unstable Cervical Spine Fracture After Penetrating Neck Injury: A Rare Entity in an Analysis of 1,069 Patients.
The Journal of Trauma, Injury, Infection, and Critical Care. April 2001;70:870-872
Mazolewski PJ, Curry JD, Browder T, Fildes J. Computed Tomographic Scan Can Be Used for Surgical Decision Making in Zone II Penetrating Neck
Injuries. The Journal of Trauma, Injury, Infection, and Critical Care. August 2001;51:315-319
Munera F, Soto JA, Palacio A, et. al. Diagnosis of Arterial Injuries Casued by Penetrating Trauma to the Neck: Comparison of Helical CT Angiography and
Conventional Angiography. Journal of Radiology. August 2000;216:356-362
Newton, K. Chapter 41: Neck. In: Walls, Ron M, editor. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Mosby Elsevier 2010. p. 377386
Osborn TM, Bell RB, Qaisi W, Long WB. Computed Tomographic Angiography as an Aid to Clinical Decision Making in the Selective Management of
Penetrating Injuries to the Neck: A Reduction in the Need for Operative Explorations. The Journal of Trauma, Injury, Infection, and Critical Care. June
2008;64:1466-1471
Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging Evaluation of Penetrating Neck Injuries. July 2010;30:869-886
Tisherman SA, Bokhari F, Collier B. Clinical Practice Guideline: Penetrating Zone II Neck Trauma. The Journal of Trauma, Injury, Infection, and Critical
Care. May 2008;64:1392-1405
Thoma M, Navsaria PH, Edu S, Nicol AJ. Analysis of 203 Patients with Penetrating Neck Injuries. World Journal of Surgery. 2008;32:2716-2723
Vick LR, Islam S. Adding Insult to Injury: Neck Exploration for Penetrating Pediatric Neck Trauma. The American Surgeon. November 2008;74:1104-1106
Any Questions?