1 / 61

Penetrating and Blunt Neck Injuries “Deadly Missed Injuries”

Penetrating and Blunt Neck Injuries “Deadly Missed Injuries”. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Types of Injury - Penetrating. 40% do not involve important structure GSW direct and delayed type of injury Structures major vein 15-25% major artery 10-15%

arleen
Télécharger la présentation

Penetrating and Blunt Neck Injuries “Deadly Missed Injuries”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Penetrating and Blunt Neck Injuries“Deadly Missed Injuries” Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. Types of Injury - Penetrating • 40% do not involve important structure • GSW direct and delayed type of injury • Structures • major vein 15-25% • major artery 10-15% • pharynx or esophagus 5-15% • larynx or trachea 4-12% • major nerves 3-8%

  3. Type of Injury - Blunt • Cervical spine • Vascular injuries • internal carotid artery • vertebral carotid artery • Aerodigestive • esophageal (rare) • larynx

  4. Deadly Missed Neck Injuries • Carotid Artery Injury • Esophageal Perforation • Laryngotracheal Injury

  5. Diagnosis • Significant injuries often asymptomatic • 25% positive symptoms and 25% positive signs • PE is often deceptively negative for severe injury • Symptoms variable and delayed • internal carotid artery > 2 weeks • esophageal • Weigelt (A J Surg 1987) 3/10 no signs or symptoms • laryngeal • more likely to have presenting symptoms/signs • voice change, SOB, hemoptysis

  6. Keys to Diagnosis • Little need for labs • High index of suspicion • Sense of urgency • Operation vs radiology

  7. Case #1 • 21 yom with GSW to right neck without exit site • c/o pain in throat/right neck • VS : HR 110, BP 130/70, RR 27 sats 98% (40%) • PE: • mild swelling right neck, non-pulsetile • ??

  8. Penetrating Neck Zones

  9. Vascular Injuries - Physical Exam • Penetrating • Fogelman et al (Am J Surg,1956) • 43% hemodynamically stable • 70% no sign of bleeding • Carducci et al(Ann Emerg Med, 1985) • 1/3 no signs/symptom • Apffelstaedt et al (World J Surg, 1994) • Prospective study, 335 patients • SW penetrating platysma • clinical signs absent 30% of positive neck explorations

  10. Physical Exam - Penetrating • Reliable for significant vascular injuries • Demetriades et al (Br J Surg, 1993) • prospecitive 335 patients, detailed written protocol • 7/335 required angiography • 269/335 nonoperative managed • 2 required subsequent operations for vascular injury • no complications • Demetriades et al (World J Surg, 1996) • prospective 223 patients, strict written protocol(Doppler) • 160/223 no clinical signs underwent angio • no vascular injury requiring treatment

  11. Overview Management Penetrating Neck • Zone I • routine angiography • ? Esophageal evaluation (EGD, swallow) • Airway evaluation (bronchoscopy) • Zone II • selective management vs operative • neither approach superior (Asensio et al, Surg Clin N Amer, 1991) • Zone III • routine angiography

  12. Angiography • Recommended in Zone I and III • difficult to assess clinically • difficulty surgical exploration • Policy reduces nontherapeutic intervention • Costs (Demetriades et al, Br J Surg, 1993) • Zone I only 5% required operation • Zone III only 13% required operation

  13. Zone III GSW

  14. Zone III GSW

  15. Management Penetrating Zone II • Mandatory exploration • Advantages • decreased injuries • up to 25% unexpected injuries found • low morbidity/mortality • Disadvantages • report up 67% negative exploration • Recommendations • Zone II injuries with/without instability • GSW that cross midline

  16. Transcervical GSW • More likely to involve vital structures • 73% vs 31% (GSW not cross midline) • Hirshberg et al, Am J Surg 1994 • retrospective 41 patients • 30(83%) positive for cervical injury • recommends mandatory exploration • Demetriades et al, J of Trauma, 1997 • prospective, 33 patients • 73% injury to vital organ, only 21% therapeutic operation

  17. Stab vs Gunshot Wounds • Anecdotal suggestion • explore GSW, non-operative SW • not supported in literature • Prospective study (Demetriades et al, Br J Surg, 1993) • 97 GSW, 89 SW • GSW higher incidence of clinical signs than knives (35% vs 19%) • GSW more likely injuries • therapeutic operation: GSW 16.5%, SW 10.1%

  18. Zone II - “Selective Conservatism” • If hemodynamically stable • angiography, contrast study, endoscopy , +/- laryngoscopy • Exploration if positive study • Negative neck exploration 20% • Missed injuries negligible (Jurkovich et al, Trauma, 1985) • Disadvantages • cost and time • iatrogenic (CVA, esophageal perfs)

  19. Acute Management Zone II Injury

  20. Treatment- Specific Injuries • Carotid injuries • 22% of penetrating cervical vascular injuries • mortality 10-20% (in-hospital) • Repair vs ligation • repair if possible in absence of neurologic deficits • prefer saphenous vein, but prosthetics ok • if internal carotid injuries, transposition of external carotid • ligation in neurologically intact for high internal carotid injury if very difficult or impossible

  21. Treatment- Specific Injuries • Carotid injury • Presence of neurologic deficits • controversial • ? Concern of postvascularization hemorrhagic infarct • increased risk if evidence of sever anemic infarct or edema • recommend repair • if deficits are short of coma • no evidence of anemic infarct • patent distal carotid

  22. Treatment- Specific Injuries • Carotid artery occlusion with symptoms • may result in late local or neurologic complications • may develop pseudoaneurysm or rupture • recommend repair if • technically feasible • not at base of skull

  23. Carotid Intimal Flap

  24. Treatment - Specific Injuries • Minor carotid injuries (intimal flaps) • natural history not known • controversial: observation vs aggressive approach • ? role of duplex for decision making • role of anti-platelet unproven, but used

  25. Vertebral Artery Pseudoaneurysm

  26. Management - Specific Injuries • Vertebral artery • increased frequency secondary liberal angio • 10% of major vascular injuries • 67% have association with major cervical injury mainly spine • isolate injury asymptomatic in 1/3 patients • thrombosis rarely lead to neurologic sequelae • angiographic embolization standard of care if bleeding

  27. Complications • Nonoperative Management • delayed bleeding • CVA (dissection, emboli) • pseudoaneurysm • sepsis (missed esophageal leak) • Operative Management • injury to nerves (vagus, hypoglossal, recurrent) • blood loss • missed injury (particularly esophageal)

  28. Summary Treatment - Vascular Injury • Surgical exploration unstable and stable Zone II (board answer) • Angiography Zone I and III • ? Nonoperative management stable Zone II • depends on expertise and facilities • Other interventions • embolization high carotid or vertebral artery • endovascular stent (pseudoaneurysms) • anticoagulation blunt carotid/vertebral artery

  29. Case #2 • 56 yom s/p MVC driver vs pole • Found unconscious at scene, intubated • VS: HR 90, BP 110/80, sat 100% • PE: • abrasions to left shoulder/mid chest/LUQ • GCS 7, pupil equal/reactive • ??

  30. Carotid Artery Dissection Internal Carotid Occlusion

  31. Blunt Carotid Injury • Low incidence (0.08-0.25%) • Male 76%, Mean age 35 +/- 2 yrs • Most commonly intimal disruption • ? asymptomatic • Louisville U. (1998) 24 BCI all symptomatic • Colorado U. (1998) 12/56 asymptomatic • Often delayed diagnosis (Krajewski, Ann Surg 1980) • 58% > 10hrs • 36% > 24 hrs

  32. Eiology MVC 41% (seat belt not a factor) Fall/ped struck 14% MCC 11% other 22% ski bike assault near hanging horseback Associated injuries CHI 65% facial fx 60% thoracic 51% basilar skull fx 32% extremity fx 32% abdominal 30% pelvic fx 16% cervical fx 5% none 16% Blunt Carotid Injury Biffl et al, Ann Surg, 1998

  33. Diagnosis - Vascular Injury • Careful PE • hematomas, bruit, thrill • Horner’s syndrome • limb paresis or paralysis • deep coma • Delayed up to several days • PITFALL: Failure to consider blunt carotid injury with negative CT and CNS changes delayed

  34. Blunt Carotid Injury • Screening asymptomatic (Biffl et al, 1998) • severe neck hyperflexion, flexion, or rotation • significant soft-tissue injury anterior neck • cervical spine fracture • displaced midface fx or mandibular fx associated with a major injury mechanism • basilar skull fx involving sphenoid/mastoid/petrous/foramen lacerum

  35. Blunt Carotid Injury • Biffl et al, 1998 (continued) • before screening 12/12429 (0.1%) • after screening 25/2902 (0.86%) • only 28% had lateralizing signs/symptoms • 25% had concomitant head injury/depressed MS • symptoms and timing • > 24 hrs - 28% • > 1 week - 8.3 %

  36. Blunt Carotid Injury • Biffl et al, 1998 (continued) • Outcome by symptoms at diagnosis • Dead Major Minor Normal • Asymptomatic 1 1 0 11 • Symptomatic 7 6 5 6

  37. Blunt Carotid Injury • Biffl et al, 1998 • Treatment • Operative =1/37 • Anticoagulation = 24/37 • endovascular stent 10/24 • No intervention = 11/37 • Outcome • Dead Major Minor Normal • Anticoagulation 1 6 4 13 • No Anticoagulation 3 1 1 4

  38. Blunt Carotid Injury • Biffl et al, 1998 • Complications • angiography (2) - groin hematoma(1), CVA (1) • hemorrhagic • 54% rebleeding ( transfusions and/or cessation) • Summary • Anticoagulation improves outcome • confirmed Fabian et al, Ann Surg, 1996 • Aggressive screening ( ? Diagnostic test) • Optimal intervention ? • Stenting pseudoaneurysm

  39. Blunt Carotid Injury Contraindicaton to Heparin No Yes Heparin Observe Angiography 7-10 d Pseudoaneurysm Yes No Coumadin 3 mos Heparin/Stent or OR

  40. Vascular Injury - Radiologic Test • C- spine films • r/o fractures (spine/larynx) • ? subcutaneous air • anterior cervical soft tissue swelling • tracheal deviation • ? CXR/ skull xray (where’s the bullet ?)

  41. BCI and Anticoagulation Fabien et al, Surg, 1996

  42. Vascular Injury - Radiologic Test • Duplex • can be used for carotid injuries Zone II only • as useful as angio in stable patients with Zone II injury (Thal, Trauma, 1991) • operator dependent • CT Angiogram • limited studies • ? comparable to angiogram (missed blunt injuries) • advantage: no risk of CVA

  43. Vascular Injury - Radiologic Test • Angiography • gold standard (4 vessel runoff) • Indications • proximity to carotid with or without hematoma • shotgun blasts with ? multiple artery segments injuries • precise localization for planning proximal or high carotid injury • blunt trauma with extensive soft-tissue injury • blunt trauma with neurologic loss unexplained by CT

  44. Case #3 • 29 yof restrained driver, head-on MVC • reported striking face/neck on steering wheel c/o neck/throat pain • airway patent without voice change • PE: • anterior neck crepitus • no stridor • ??

  45. Diagnosis - Esophageal • Blunt esophageal injury rare • High index of suspicion in blunt trauma • Penetrating trauma - evaluation part of a complete work-up • If missed, high morbidity/mortality

  46. GSW Anterior-Posterior Neck

  47. Esophageal Injury - Diagnostic Test • Contrast swallow • Extravasation is diagnostic • Negative study is not reliable (particular in neck with gastrograffin) • 50% of leaks missed with gastrograffin • 25% of leaks missed with barium

  48. Gastrograffin swallow

  49. Esophageal Injury - Diagnostic Tests • Controversy of initial contrast to use • gastrograffin • pneumonitis if aspirated • barium • increased inflammation/infection in the mediastium • Rec: If gastrograffin study is negative, repeat swallow this barium. Avoid gastrograffin in patients without gag/cough

  50. Esophageal Injury - Diagnostic Test • Endoscopy • Generally recommended when contrast swallow is negative, but suspicion is high • Perforations often readily seen, however • 50% missed (Weigelt et al Am J Surg 1987) • missed in pharynx and cervical esophagus • missed in patients on ventilator (poor expansion of esophagus) • Combination of swallow/esophagoscopy reduces missed injuries to < 5%

More Related