Management of Penetrating Neck

Trauma
Ottawa Civic

MVA, aphasia, R hemiplegia

Types of Weapons

Low velocity knives, ice picks, glass

High velocity handguns, shotguns, shrapnel

Guns

Ballistics

Anatomy

Anatomy

Incidence and Mortality

Signs of Injury:

Signs of Injury:

Initial Management

Management of the Stable Patient:

The Standard:

The Standard:

Based on wartime experiences

Fogelman et al (1956) :

immediate neck exploration-> better outcomes in

vascular injuries.
negative neck explorations in > 50%

Arteriogram?

screening tool before exploration

zone 1 and 3 injuries

hard to detect on physical

Safe answer on board exam

Arteriogram

Flint et al (1973):

negative P.E. in 32% of pts. with major zone 1

vascular injury.

Arteriogram can be accompanied by

treatment (e.g. embolization).

A Newer Algorithm

Mansour et al 1991 retrospective study

Newer Algorithm (Mansour)

63% of the study population was in the
observation group.
Overall mortality 1.5%

similar to those in more rigorous treatment

protocols.

Similar results obtained in other large

studies with similar protocols (e.g. Biffi et
al 1997).

NOTE: Arteriogram in asymptomatic patients

with zone 1 injury.

Points of Controversy:

Most trauma surgeons accept observation of

select patients similar to the Mansour
algorithm.
Study by Eddy et al

questions the necessity for arteriogram /

esophagoscopy in asymptomatic zone 1 injury
(use of P.E. and CXR resulted in no false
negatives).

Other noninvasive modalities than

arteriogram exist for screening patients for
vascular injury.

CT scan

Can id weapon trajectory and structures

only in stable patients.
Gracias et al (2001)

CT scan in stable patients:

able to save patients from arteriogram indicated by other

protocols 50% of the time
avoid esophagoscopy in 90% of tested patients who might
otherwise have undergone it.

Duplex Ultrasonography

Requires the presence of reliable technician

and radiologist.
A double blinded study by Ginsburg et al
(1996) showed 100% true negative, 100%
sensitivity in detecting arterial injury, using
arteriography as the gold standard.

Is this really wise??

Incision for Neck Exploration:

Incisions for Neck Exploration:

Management of Vascular Injuries:

Common carotid:

Internal carotid:

Shunting is usually necessary

Vertebral:

repair preferred over ligation in almost all cases.

Saphenous vein graft may be used.
Shunting is rarely necessary.
Thrombectomy may be necessary.

Angiographic embolization
proximal ligation can be used if the contralateral vertebral
artery is intact.

Internal Jugular: Repair vs. ligation.

Esophageal Injury:

Diagnosis:

esophagoscopy and esophagram in

symptomatic patients.
Injection of air or methylene blue in the mouth
may aid in localizing injuries.

Controlled fistula with T-tube

exteriorization of low non-repairable wounds

Small pharyngeal lesions above arytenoids

can be treated with NPO and observation
5-7 days
All patients should be NPO for 5-7 days.

Laryngeal/Tracheal Injury

Thorough Direct Laryngoscopy for suspicious wounds

Tracheotomy for suspected laryngeal injury

Thoracic Trauma

Thoracic Trauma

2nd leading cause of trauma deaths

after head injury

10-20% of all trauma deaths

Many deaths are preventable

Thoracic Trauma

Mechanisms of Injury

Blunt Injury

Deceleration
Compression

Penetrating Injury
Combination

Thoracic Trauma
Anatomical

Injuries

Thoracic Cage (Skeletal)

Cardiovascular
Pleural and Pulmonary
Mediastinal
Diaphragmatic
Esophageal
Penetrating Cardiac

Thoracic Trauma

Hypoxia

Hypercarbia

in intrathoracic pressure relationships

level of consciousness

Impairments to cardiac output

hypovolemia
pulmonary V/P mismatch
in intrathoracic pressure relationships

blood loss
increased intrapleural pressures
blood in pericardial sac
myocardial valve damage

Acidosis final result

hypoperfusion of tissues

Thoracic Trauma
Initial

exam directed toward life

threatening:

Injuries

Open pneumothorax
Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade

Thoracic Trauma
Assessment

Mental Status

narrow PP, hyper- or hypotension, pulsus paradoxus

Ventilatory rate & effort

absent, tachy or brady

BP

decreased

Pulse

Findings

tachy- or bradypnea, labored, retractions

Skin

diaphoresis, pallor, cyanosis, open injury,

ecchymosis

Thoracic Trauma
Assessment

Neck

contusions, tenderness, asymmetry, abN a/e,

bowel sounds, abnormal percussion, open
injury, impaled object, crepitus, hemoptysis

Heart Sounds

tracheal position, SQ emph, JVD, open injury

Chest

Findings

muffled, distant, regurgitant murmur

Upper abdomen

contusion, open injury

Thoracic Trauma
Assessment

Findings

ECG (ST segment abnormalities,

dysrhythmias)

History

Dyspnea
Pain
Past hx of cardiorespiratory disease
Restraint devices used
Item/Weapon involved in injury

Thoracic Trauma

Specific Injuries

Rib Fracture
MC

chest wall injury from direct

trauma
More common in adults than children
Especially common in elderly

Most

commonly 5th - 9th ribs

Poor protection

Rib Fracture
Fractures

of 1st and 2nd second

require high force
Frequently have injury to aorta or
bronchi
Occur in 90% of patients with tracheobronchial rupture
May injure subclavian artery/vein

30%

will die

Rib Fracture
Fractures

of 10 to 12th ribs can cause

damage to underlying abdominal
solid organs:

Liver
Spleen
Kidneys

Rib Fracture
Management
PPV
Analgesics for isolated trauma
Non-circumferential splinting
Monitor elderly and COPD patients
closely

Broken ribs can cause decompensation

Patients will fail to breathe deeply and cough,
resulting in poor clearance of secretions

Sternal Fracture
Uncommon,

5-8% in blunt chest

trauma
Large traumatic force
Direct blow to front of chest by

Deceleration

steering wheel
dashboard

Other object

Sternal Fracture
25

- 45% mortality due to associated

trauma:

Disruption of thoracic aorta

Tracheal or bronchial tear
Diaphragm rupture
Flail chest
Myocardial trauma

High

incidence of

myocardial contusion, cardiac tamponade or

pulmonary contusion

Sternal Fracture
Management
Establish airway
High concentration oxygen
Assist ventilations as needed
IV NS/LR

Restrict fluids

Rule out associated injuries

Flail Chest
Usually

secondary to blunt trauma

Most commonly in MVA

Also results from

falls from heights

industrial accidents
assault
birth trauma

More

common in older patients

Flail Chest
Mortality

rates 20-40% due to

associated injuries
Mortality increased with
advanced age
seven or more rib fractures
three or more associated injuries
shock
head injuries

Flail Chest
Consequences

of flail chest

Respiratory failure due to

pulmonary contusion
inadequate diaphragm movement

Paradoxical

movement of the chest

must be large to compromise ventilation

Increased work of breathing

decreased
pain

chest expansion

Flail Chest
Suspect spinal injuries
Establish airway
Assist ventilation

Treat hypoxia from underlying contusion

Promote full lung expansion

Consider need for intubation and PEEP

Mechanically stabilize chest wall

questionable value

Flail Chest
Management

IV of LR/NS

Avoid rapid replacement in hemodynamically

stable patient
Contused lung cannot handle fluid load

Monitor EKG

Chest trauma can cause dysrhythmias

Simple Pneumothorax
Incidence

10-30% in blunt chest trauma

almost 100% with penetrating chest
trauma
Morbidity & Mortality dependent on

extent of atelectasis
associated injuries

Simple Pneumothorax
a # rib lacerates lung
Usually well-tolerated in the young &
healthy
Severe compromise can occur in the
elderly or patients with pulmonary
disease

Degree

of distress depends on amount

and speed of collapse

Simple Pneumothorax
HDI and respiratory distress
High index of suspicion
Chest tube when in doubt before CXR

Open Pneumothorax

If the trauma patient does not ventilate

well with an open airway, look for a hole

May be subtle
Abrasion with deep punctures

Opening in the chest wall

Sucking sound on inhalation
HDI/resp distress
SQ Emphysema

Open Pneumothorax
Profound hypoventilation may occur
communication between pleural space
and atmosphere

Prevents

development of negative
intrapleural pressure

Results in ipsilateral lung collapse

inability to ventilate affected lung

Open Pneumothorax

V/Q Mismatch

shunting
hypoventilation
hypoxia
large functional dead space

Pressure may build within pleural

space
Return from Vena cava may be
impaired

Open Pneumothorax
Cover chest opening with occlusive
dressing
Assist with positive pressure
ventilations prn
Monitor for progression to tension
pneumothorax

Tension Pneumothorax
Incidence

Penetrating Trauma
Blunt Trauma

Morbidity/Mortality

Severe hypoventilation
Immediate life-threat if not managed
early

Tension Pneumothorax
Pathophysiology

One-way valve forms in lung or chest wall

Air

enters pleural space, but cannot leave

Pressure collapses lung on affected side

Mediastinal shift to contralateral side

Reduction in cardiac output

Increased

intrathoracic pressure
deformed vena cava reducing preload

Tension Pneumothorax
Severe dyspnea extreme resp
distress
Restlessness, anxiety, agitation
Decreased/absent breath sounds
Worsening or Severe Shock
Cardiovascular collapse

Tachycardia
Weak pulse
Hypotension
Narrow pulse pressure

Tension Pneumothorax

Jugular Vein Distension

absent if also hypovolemic

Hyperresonance to percussion
Subcutaneous emphysema
Late

Tracheal
Cyanosis

shift away from injured side

Tension Pneumothorax

Recognize & Manage early

Establish airway
Needle thoracostomy then chest tube

Tension Pneumothorax

Decompress with 14g (lg bore), 2-inch needle

Midclavicular line: 2nd intercostal space
Midaxillary line: 4-5th intercostal space
Go over superior margin of rib to avoid blood
vessels
Be careful not to kink or bend needle or
catheter
If available, attach a one-way valve

Hemothorax

Most common result of major trauma

to the chest wall
Present

in 70 - 80% of penetrating and

major non-penetrating trauma cases

Associated with pneumothorax

Rib fractures are frequent cause

Hemothorax
Each can hold up to 3000 cc of blood
Life-threatening often requiring chest tube
and/or surgery
If assoc. with great vessel or cardiac injury

50% die immediately

25% live five to ten minutes
25% may live 30 minutes or longer

Blood loss results in

Hypovolemia
Decreased ventilation of affected lung

Hemothorax

Accumulation of blood in pleural space

penetrating or blunt lung injury

chest wall vessels
intercostal vessels
myocardium

Massive hemothorax indicates great

vessel or cardiac injury
Intercostal

artery can bleed 50 cc/min

Hemothorax

Chest tube, go to OR if

1000 cc out on insertion

200 cc/h for 4 hours

Pulmonary Contusion
Pathophysiology

Blunt trauma to the chest

Rapid deceleration forces cause lung to strike chest

wall
high energy shock wave from explosion
high velocity missile wound
low velocity as with ice pick

Most common injury from blunt

thoracic trauma

30-75% of blunt trauma

mortality 14-20%

Pulmonary Contusion
Pathophysiology

Rib Fx in many but not all cases

Alveolar rupture with hemorrhage and
edema

increased capillary membrane permeability

Large vascular shunts develop

Gas exchange disturbances

Hypoxemia
Hypercarbia

Pulmonary Contusion
Assessment Findings
Evidence of blunt chest trauma
Cough and/or Hemoptysis
Apprehension
Cyanosis
CXR changes late

Pulmonary Contusion
Management
Supportive therapy
Early use of positive pressure
ventilation reduces ventilator therapy
duration
Avoid aggressive crystalloid infusion
Severe cases may require ventilator
therapy

Myocardial Contusion
Most

common blunt injury to heart

Usually due to steering wheel
Significant cause of morbidity and
mortality in the blunt trauma
patient

Myocardial Contusion
Pathophysiology
Behaves like acute MI
Hemorrhage with edema

Hemopericardium may occur from

lacerated epicardium

Cellular injury
vascular damage may occur

May produce arrhythmias

hypotension unresponsive to fluid or

drug therapy

Myocardial Contusion
Cardiac arrhythmias following blunt
chest trauma
Angina-like pain unresponsive to
nitroglycerin
Precordial discomfort independent of
respiratory movement
Pericardial friction rub (late)

Myocardial Contusion

ECG Changes

Persistent tachycardia
ST elevation, T wave inversion
RBBB
Atrial flutter, Atrial fibrillation
PVCs
PACs

Myocardial Contusion

IV LR/NS

ECG

Cautious fluid administration due to injured

myocardium
Standard drug therapy for arrhythmias
12 Lead ECG if time permits

Admit to monitored evironment

Pericardial Tamponade

Incidence

Usually associated with penetrating trauma

Rare in blunt trauma
Occurs in < 2% of chest trauma
GSW wounds have higher mortality than stab
wounds
Lower mortality rate if isolated tamponade

 Tamponade

is hard to diagnose

Hypotension is common in chest trauma

Heart sounds are difficult to hear
Bulging neck veins may be absent if
hypovolemia is present
High index of suspicion is required

Pericardial Tamponade
Pathophysiology

Space normally filled with 30-50 ml of

straw-colored fluid

lubrication
lymphatic discharge
immunologic protection for the heart

Rapid accumulation of blood in the

inelastic pericardium

Pericardial Tamponade
Pathophysiology

Heart is compressed decreasing blood

entering heart

Myocardial perfusion decreased due to

Decreased diastolic expansion and filling

Hindered venous return (preload)
pressure effects on walls of heart
decreased diastolic pressures

Removal of as little as 20 ml of blood

may drastically improve cardiac output

Pericardial Tamponade

Becks Triad
Resistant

hypotension
Increased central venous
pressure
distended

neck/arm veins in
presence of decreased arterial BP

Small

quiet heart

decreased

heart sounds

Pericardial Tamponade

Signs and Symptoms

Narrowing pulse pressure

Pulsus paradoxicus
Radial

pulse becomes weak or

disappears when patient inhales
Increased intrathoracic pressure
on inhalation causes blood to be
trapped in lungs temporarily

Pericardial Tamponade
Management
ECHO if stable to diagnose
In ER

consider

pericardiocentesis
Pericardial window followed by
sternotomy in OR

Traumatic Aortic Dissection/Rupture

Caused

By:

Motor Vehicle Collisions

Falls from heights
Crushing chest trauma
Animal Kicks
Blunt chest trauma

15% of all blunt trauma deaths

Traumatic Aortic Dissection/Rupture

1

of 6 persons dying in MVCs has

aortic rupture
85% die instantaneously
10-15% survive to hospital

1/3 die within six hours

1/3 die within 24 hours
1/3 survive 3 days or longer

Must

have high index of suspicion

Traumatic Aortic Dissection/Rupture

Separation of the aortic intima and media

Blood enters media through a small

intima tear

Tear 2 high speed deceleration at points of

relative fixation

Thinned layer may rupture

Descending aorta at the isthmus distal to

left subclavian artery most common site
of rupture

ligamentum arteriosom

Traumatic Aortic Dissection/Rupture

Assessment

Findings

Retrosternal or interscapular pain

Pain in lower back or one leg
Respiratory distress
Asymmetrical arm BPs
Upper extremity hypertension with

Decreased femoral pulses, OR

Absent femoral pulses

Dysphagia

CXR

Work up

CTA

Angio is rarely used

Address other injuries first

Ideally, repaire when stable

Stent vs open

Diaphragmatic Penetration

Suspect intra-abdominal trauma with any

injury below 4th ICS
Suspect intrathoracic trauma with any
abdominal injury above umbilicus

Diaphragmatic Rupture
Usually

due to blunt trauma but

may occur with penetrating trauma
Usually life-threatening
Likely to be associated with other
severe injuries

Diaphragmatic Rupture
Pathophysiology

Compression to abdomen resulting in

increased intra-abdominal pressure

abdominal contents rupture through diaphragm into

chest
bowel obstruction and strangulation
restriction of lung expansion
mediastinal shift

90% occur on left side due to

protection of right side by liver

Diaphragmatic Rupture

Assessment Findings

Decreased breath sounds

Usually unilateral
Dullness to percussion

Dyspnea or Respiratory Distress

Scaphoid Abdomen
Usually impossible to hear bowel sounds

Management

suspect
NG tube
CT
Laparoscopy

Sensitive and specific

Esophageal Injury
Penetrating

Injury most frequent

cause
Rare in blunt trauma
Can perforate spontaneously

violent emesis
carcinoma

Esophageal Injury
Assessment

Findings

Pain, local tenderness

Hoarseness, Dysphagia, Respiratory
distress
Mediastinal esophageal perforation

mediastinal emphysema / mediastinal crunch

SQ Emphysema

Shock
Abx
resuscitation

Early diagnosis
Gastrographin -> dilute Ba
Repair vs exclude

Tracheobronchial Rupture
Uncommon
less

injury

than 3% of chest trauma

Occurs

with penetrating or blunt chest

trauma
High

mortality rate (>30%)

Respiratory Distress
Obvious SQ emphysema
Hemoptysis

Especially of bright red blood

Signs

of tension pneumothorax
unresponsive to needle decompression

Tracheobronchial Rupture
Majority (80%) occur at or near carina
rapid movement of air into pleural
space
Tension pneumothorax refractory to
needle decompression

Consider early intubation

intubating right or left mainstem may be life saving

If arrest and suspect air embolysm, may have to do
ERT

Damage control

Damage control principle

ED Thoractomy

Thoracotomy performed in ER
for resuscitation of patients arriving in
extremis
Plan to take to OR afterwards
AIM:

Expeditious control of hemorrhage

Maximization of coronary and cerebral perfusion
Release of pericardial tamponade
Tx of massive air-embolysm

Procedure Left Anterolateral

Thoracotomy

Clamshell Thoracotomy

Release Pericardial Tamponade

Control Intrathoracic Hemorrhage

Eliminate massive air embolism or

bronchopleural fistula
Post intubation & positive pressure
ventilation
Get air transfer across traumatic
alveolovenous channels
Pulmonary hilar cross clamping
Air aspirated from L ventricular apex and
aortic root
Cardiac massage

Perform Open Cardiac Massage

Bimanual internal massage with hands in a

hinged clapping motion
Ventricular compression proceeding from
apex to base of heart

Occlude Descending Thoracic Aorta

Futile?

Overall survival ~4-5%

Little to Lose

risk to Health care workers

Risk blood contact

26% trauma pts HIV+ or Hepatitis+

Health care costs

J Trauma. 1998 Jul;45(1):87-94

Selective Application of ED
Thoracotomy

Mechanism of Injury
Presence of Vital Signs
Location of Injury
Other Signs of Life

Survival based on mechanism

J Trauma. 1998 Jul;45(1):87-94

Presence of vital signs

J Trauma. 1998 Jul;45(1):87-94

Survival based on organ injured

JACS 2000 Mar;190(3):288-98.

Other Signs of Life (SOL)

JACS 2000 Mar;190(3):288-98.

What about PEA?

26/62 (42%) ED Thoracotomy survivors had PEA requiring CPR

JACS 199:211-215, 2004

Conclusions

ER thoracotomy considered in pts w/:

Presence of vital signs in field or hospital

Better results in penetrating cardiac injury
Results w/ Blunt trauma poor, but survivors exist

PEA after penetrating trauma from stabs

Up to 70% good outcomes

Contraindicated in pts with:

No vital signs, prolonged asystole and unwitnessed

arrest/loss of SOL

JACS 199:211-215, 2004

Finally
PEA after blunt trauma?
Typically poor outcome, but occasionally
will have a survivor
If CPR > 5 min, contraindicated

References and thanks

Thank God for internet and Google

several websites specifically:

http://www.adhb.govt.nz/trauma/presentations/Forums/major%20
chest%20injuries/sld001.htm
http://www.templejc.edu/dept/ems/Pages/PowerPoint.html
http://www.mssurg.net
www.nordictraumarad.com/Syllabus06/mo
%2015/NORDTERpenetrating.pdf
www.iformix.com/spu/chest_trauma.ppt
Greenfield textbook of surgery