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Penetrating Neck Injuries

Penetrating Neck Injuries. Penetrating Neck Injuries. Case 1 19 year old male in Casuarina stabbed back of neck with steak knife (8cm) Zone II injury haemodynamically stable. Penetrating Neck Injuries. Penetrating Neck Injuries. Penetrating Neck Injuries. Case 2 27 year old male

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Penetrating Neck Injuries

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  1. Penetrating Neck Injuries

  2. Penetrating Neck Injuries • Case 1 • 19 year old male in Casuarina • stabbed back of neck with steak knife (8cm) • Zone II injury • haemodynamically stable

  3. Penetrating Neck Injuries

  4. Penetrating Neck Injuries

  5. Penetrating Neck Injuries • Case 2 • 27 year old male • stabbed in anterior triangle • Zone I injury • required resuscitation at scene • fixed dilated pupils on presentation

  6. Penetrating Neck Injuries

  7. Penetrating Neck Injuries • Epidemiology • stab wounds or low velocity missiles • young, otherwise healthy and intoxicated • carotid artery involved in 6% • account for 22% of all cervical vascular trauma

  8. Penetrating Neck Injuries • Classification • Anterior/Posterior neck triangles • Zones • I = Between clavicle and cricoid • II = cricoid and angle of mandible • III = angle of mandible to BOS

  9. Penetrating Neck Injuries • Zone II most common (47%) • Zone I (18%) and Zone III (19%) • multiple zones (16%)

  10. Penetrating Neck Injuries • Injuries • arterial • venous • neurological • oesophagus • airways

  11. Penetrating Neck Injuries • Findings: airways • airways obstruction • haemoptysis • air bubbling through wound • subcutaneous emphysema • hoarseness • painful swallowing • haematemesis

  12. Penetrating Neck Injuries • Findings: vascular • haemodynamic instability • haematoma • reduced pulses (CA, STA, RA) • bruit/thrill

  13. Penetrating Neck Injuries • Findings: neurological • GCS • focal UMN signs • cranial nerves (VII, IX, X, XI, XII) • cervical spinal cord • Horner’s syndrome • Brachial plexus

  14. Penetrating Neck Injuries • Management • ABCD • surgical exploration for ‘hard’ signs of vascular injury (shock, active beeding, enlarging haematoma, bruit/thrill) • stable patients with Zone I and III injuries: angiography with selective intervention

  15. Penetrating Neck Injuries • Zone II Controversies • Mandatory versus Selective exploration • Accuracy of physical examination • investigation

  16. Penetrating Neck Injuries • Mandatory exploration • Apffelstaedt et al. World J Surg 1994 • 393 consecutive patients over 20 months • 30% of (+) neck explorations had absent clinical signs • low morbidity/mortality in negative explorations • investigations have false (-) and false (+) rates

  17. Penetrating Neck Injuries • Selective exploration • Demetriades et al. World J Surg 1997 • 223 patients over 20 months, 176 had angiography • 34(19%) had positive angiography, 8% required treatment • 34 patients with soft signs, 8 had (+) angiogram but only 1 required treatment • mandatory exploration leads to high rate (30-89%) of unnecessary operations

  18. Penetrating Neck Injuries • Physical Examination • Sekharan et al, J Vasc Surg 2000 • 145 zone II injuries, retrospective chart review • 31 had hard signs, 90% (+) exploration • 23 had angiogram due to proximity to major structures or involving more than 1 zone. • 91patients were observed without imaging or surgery with no evidence of subsequent vascular injury up to 2 weeks.

  19. Penetrating Neck Injuries • Physical Examination • accuracy of 99% in diagnosing significant vascular injuries with a false negative rate comparable to angiography. • However most studies are prolonged retrospective studies with no uniform protocol • May miss occult lesions such as smooth narrowings, intimal irregularities and small psedoaneurysms and AV fistulas

  20. Penetrating Neck Injuries • Duplex Ultrasound • Demetriades et al. 99 patients had duplex • 11 lesions correctly identified (6 VA, 4 CA, 1 SCA) • 1 missed lesion (CCA/VA small intimal tears) • sensitivity 91%, specificity 100%, PPV 100% and NPV 99%.

  21. Penetrating Neck Injuries • CT • Mazolewski et al. J Trauma 2001 • 14 stable patients Level 2 • sensitivity 100%, specificity 91%, PPV 75% and NPV 100%

  22. Penetrating Neck Injuries • vertebral artery injury • clinical presentation and outcome related to associated injuries. • 72% have no evidence of arterial trauma • low incidence of brain stem ischaemia with unilateral VA ligation

  23. Penetrating Neck Injuries • oesophageal injury • very low prevalence • Demetriades et al • only symptomatic or obtunded patients should undergo investigations

  24. Penetrating Neck Injuries • venous injury • ligation for major cervicomediastinal venous trauma is generally well tolerated

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