GROUP 6

ENDORSEMENT
NECK TRAUMA
Preceptor: Dr. John Dominic Locsin.

 WEEK -2
Case Scenario
 22 Y/O, Male
 working in victoria plaza as packer in
grocery section.

 Chief complaint :
 patient came into ER due to a drunk man
swung a machete across patients neck and
with blood all over the his neck.
History of present illness

 A drunk man swung a machete to the patient

hitting him across the neck and patient was
rushed to the hospital.
 The patient came in the er, awake, and was
holding his neck with both hands, and with
blood all over the mans shirt.
past medical history

 no data given.

Personal and social history

He is working as a packer in grocery

section in victoria plaza.
Vital signs
 HR- 110
 RR- 28
 BP- 80/60
 Temperature- 36 .
 Physical Examination.
 The patient came in the er, awake, and was holding his neck with both
hands, and with blood all over the mans shirt.
 Vital signs were checked
 Hr 110
 Rr 28
 Bp 80/60
 Temp 36
 You asked the man his name and to your surprise, he was not able to.
answer you back. He was mouthing his words but no words were coming
out.
 You asked the patient to remove his hands so you could examine the injury,
once his hands were removed, you saw that air was moving in and out of the
patients neck wound as well as spraying of arterial blood was noted on the
wound.
Diagnostic tests

 No need of doing any further diagnostics as this

patient is having hard signs
 Salient Features:
 22-year-old / Male
 Hit by a machete in the neck
 The patient came in the ER, awake, and was holding his neck with both
hands, and with blood all over shirt.
 Vital signs: HR 110, RR 28, Bp 80/60, Temp 36
 He was mouthing his words but no words were coming out
 Air was moving in and out of the patients neck wound as well as spraying of
arterial blood was noted
 During neck exploration, it was noted that Trachea was completely severed
between the 1st and 2nd tracheal ring, and 40% of the esophagus was also
transected. The left internal jugular vein was transected as well
 Clinical impression:

 HYPOVOLEMIC SHOCK CLASS 3 SECONDARY TO

PENETRATING NECK INJURY ZONE 2, WITH GRADE 1
ESOPHAGEAL INJURY, GRADE 5 TRACHEAL INJURY,
PARTIAL TRANSECTION IF THE INTERNAL JUGULAR VEIN,
LEFT SECONDARY TO HACKING INJURY.
 Etiology of Penetrating neck injury .

 Penetrating injuries from gunshot and stab wounds are the most
common mechanism of injury in penetrating neck trauma.
 In penetrating wounds the damage is localized to the path of the
bullet or knife
 Additionally, because bullets and knives usually follow straight
lines, adjacent structures are commonly injured
 EPIDEMIOLOGY
 Penetrating neck trauma represents
approximately 5-10% of all trauma cases that
present to the emergency department. About
30% of these cases are accompanied by injury
outside of the neck zones as well
 Types:
 1. Gun shot wound (GSW): 45%
 2. Stab wound (SW): 40%
 40% do not involve important structures
Structure injured:
Major vein 15-25% Major artery 10-15%
Digestive tract (pharynx,
esophagus) 5-15% Respiratory tract(larynx,
trachea) 4-12% Major nevers 3-8% .
 PATHOPHYSIOLOGY
 Two factors in the mechanism of injury or kinematics in penetrating neck
trauma determine the extend of damage to the tissue::…

 1.Weapon characteristics
 The amount of kinetic energy delivered by
the wounding agents has to be considered
together with its interaction with the involved
tissue. (Stab wounds from violent assault,
gunshot wound, self harm, road traffic
accidents and other high velocity objects)
 2. Location of injury and human tissue involved.

 Tissue injury results from either a direct impact by the penetrating projectile or
tissue displacement from temporary cavitation..
 Wound sites and, if present, the wounding agent in the neck provide an
indcation of the likely injuy complex. .
 Vascular injury – Include partial or complete occlusion, dissection, pseudoaneurysm,
extravasation of blood or arteriovenous fistula formation..
 Arterial injury – Occurs in approx 25 % of penetrating neck injuries; carotid artery
involvement seen in approx 80% and vertebral artery in 43%. Combined carotid and
vertebral artery injury carry both hemorrhagic and neurological concern

 Aerodigestive injury – Occurs in 23 – 30 % of patient with penetrating neck injuries

and associated with high mortality rate .
 Neurological structures – Risk of involvement include the spinal cord, cranial nerves
VII – XII, peripheral nerve roots and brachial plexus. Spinal cord injury occurs
infrequently particularly in low velocity injuries such as stab wounds.
ANATOMICAL LOCATION OF NECK TRAUMA.
ZONES OF NECK TRAUMA
 DIAGNOSTIC MODALITIES
 CT angiography (CTA) is a widely accepted adjunctive screening tool. CT
angiography of the neck is the preferred imaging procedure to evaluate the
extent of injury. CT angiography may be used even in patients with "hard
signs" of injury.
 Direct laryngoscopy - For evaluation of oropharyngeal and tracheal injuries
 Flexible bronchoscopy - For delineation of tracheal and bronchial injuries
 Esophagoscopy - Flexible esophagoscopy can be used to detect an esophageal
injury with less risk of procedure-related complications than rigid
esophagoscopy (ie, rupture and complications from general anesthesia).
 CLINICAL MANIFESTATION OF PENETRATING NECK TRAUMA .

 Clinical signs of airway injury include

 Hoarseness
 stridor
 Dyspnoea
 subcutaneous emphysema(in the absence of pneumothorax )
 bubbling from the wound
 large volume hemoptysis.
 ADMITTING ORDER
 Admit the patient in the emergency ward under the service of DR. JHON DOMINIC LOCSIN
 secure the concent .
 primary survey ABC( air, breathingand circulation).
 IV- 1l of lacatated ringer solution as fast drip.
 Labs:
 blood typing and crossmatching.
 CBC
 ABG
 INR AND PTT .
 CT SACN
 Serial clinical assesment : check for vital signs, physical examination q15min.
 for emergency management stop bleeding and next perform neck exploration.
 blood transfusion
 continue suportive care
 Refer accordingly.
 MANAGEMENT OF PENETRATING CHEST INJURIES .
 ALGORITHM FOR MANAGEMENT OF PENETRATING NECK INURIES
 EMERGENCY MANAGEMENT

 ABC
 Airway, breathing and circulation should be managed immediately.
 AIRWAY

 Be prepared to obtain an airway emergently

 Intubation or cricothyrotomy
 Be a ware of cutting the neck in the region of the hematoma --
disruption which may lead to massive bleeding
 Must assume cervical spine injury until proven otherwise
 EMERGENCY MANAGEMENT

 BREATHING
 Zone I injuries with concomitant thoracic injuries .
 pneumothorax .
 hemopneumothorax .
 Tension pneumothorax .
 CIRCULATION
 Bleeding should be controlled by applying direct pressure .
 Do not clamp blindly or probe the wound depths .
 The absence of visible hemorrhage does not rule out .
 Two large bore IVs
 Careful of IV in arm unilateral to subclavian injury .
 Do not remove objects protruding from the neck in the ER .
 COMPLICATIONS

 Missed injuries or delayed diagnosis can occur after any injury to the neck,
particularly in patients presenting with minimal’ -manifestations.
 Persistent hemorrhage - Usually from a missed arterial or venous injury,
particularly in zone I and zone III .
 Pseudoaneurysms - A later sequela from a missed vascular injury, which
often is not bleeding actively during treatment .
 Arterial dissection - Incomplete transmural vessel injury may cause this
disruption between the layers of the arterial wall ..
 Fistulas - Esophagocutaneous, esophagotracheal, tracheocutaneous,
venoarterial .
 Infections - Most often occur from missed esophageal or laryngotracheal injuries;
severe inflammation, abscess formation, or mediastinitis may result.

 Stenosis or obstruction of luminal structures - May happen due to the inflammatory
response and scarring around the injured esophagus, larynx, trachea, or vessels

 Neurologic deficits - May occur due to the direct injury to a peripheral nerve or to
ischemic infarct caused by arterial injury

 Anastomotic or repair disruption - About 1% of surgical repairs leak and result in
hemorrhage, infection, or fistula formation.

 Luminal stenosis or obstruction - The surgical repair and the inflammation can cause
the narrowing of the lumen of the injured esophagus, larynx, trachea, or vessels.
 Infectious complications - Occurring particularly with injuries to the
trachea and esophagus, severe inflammatory response in the neck, abscess
formation, fistulas, or mediastinitis may result.

 Neurologic complications - Can occur as strokes related to major vascular
injuries or directly to peripheral nerves

 Thrombosis of an internal jugular vein - Can occur regardless of the
method of venorrhaphy

 Massive air emboli - May result from major venous injuries and is an
important cause of bilateral, diffuse stroke identified as hypodense lesions
on CT scan of the brain
 Tracheal and esophageal complications .
 Leaks after repair may heal spontaneously if drained adequately and
antibiotic support provided.
 Thoracic leaks may require radiographically placed drains .
 Consider stents for mid-esophageal leaks .
 Unstable or septic patients require re-operation .
 Post-operative stenosis can usually be managed with repeated endoscopic
dilatation
 Fistula , Tracheoesophageal .
 New onset cough or pneumonia .
 Repeated aspiration .
 Usually avoided if repair is buttressed adequately .
 Requires operative repair .
 Summary
 Neck injuries are uncommon but result in highest mortality of all body regions.
 Penetrating injuries are most common among neck injuries .
 The highest priority is given to airway.
 Immediate intubation should be done if there is impending airway compromise.
 Hemorrhage is other major concern for which direct pressure effectively manages
most bleeding until patient is transferred to OR .
 If hard signs are present or if there is hemodynamic instability operative
exploration needs to be done immediately .
 If patient is hemodynamically stable, then CT angiography of neck, esophagogram,
bronchoscopy can be done prior to transfer to OR .
 For asymptomatic zone 3 injuries, observation must be done. .
GROUP MEMBERS
18- MUNDLURI SAI SUDHEER .
19- MUPPALA SINDU .
20- MUPPARAJU SURENDRA .
21- MURALIDHARAN KADHAMBARY KAVIYA .
22- MURUGESAN GOWTHAM .
23- MUTHU SHANMATHI .
24- MUTHUKUMARAN RAMYA SRI .
25- MUTHYALA SIVASAI GOWTHAM .
26- MUVVA KAVYA .
27- MYLA PALLAVI .
THANK YOU
GOD BLESS YOU