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Penetrating Neck Trauma (Made Easy?)

Penetrating Neck Trauma (Made Easy?). Tim Hardcastle Trauma Surgeon Durban – South Africa. Introduction. Penetrating neck injury common in South Africa and the USA TBH >500 per year DBN >200 per year Less common in UK and Europe Fear and trepidation: limited experience

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Penetrating Neck Trauma (Made Easy?)

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  1. Penetrating Neck Trauma (Made Easy?) Tim Hardcastle Trauma Surgeon Durban – South Africa

  2. Introduction • Penetrating neck injury common in South Africa and the USA • TBH >500 per year • DBN >200 per year • Less common in UK and Europe • Fear and trepidation: limited experience • Approaches are different to H&N surgery

  3. Mechanism of Injury • Most cases will be stabs and GSW • Both can cause major injury • Bullets often more injurious • May be combined blunt / penetrating injury – impaled objects

  4. Anatomy • Dense collection of neuro-vascular and aerodigestive structures • Multiple fascia layers • Extend upward into the skull • Extend downward into the mediastinum

  5. Diagnostic Approach • Does it penetrate? • All – unstable • OPERATE • Zone 1 & 3 • Image • Attempt to use non-operative options • Zone 2 • 2 Philosophies • Explore all • Image and explore selectively* *BJS 1990: 908; World J Surg 2008: 2716; EMJ 2009: 106

  6. CONSIDER OBSERVE

  7. Resus Room • Don’t probe non-bleeding wounds • Be very wary with muscle relaxants • Fingers and Foleys are your friend • No blind clamping • Haematomas compress airways • Surgeon must be ready for surgical airway when Anaesthetist intubates

  8. Foley – Muller, Injury 1994

  9. Management of the airway • Preferably in the OR if unstable • Non-drug assisted intubation best • Use a cardio-stable agent: Etomidate* • Have a difficult airway trolley • Fibrescope • Gum elastic bougie • Surgical crico-kit (Scalpel and no 6ETT) • LMA as back-up • Good suction • Surgeon Scrubbed and ready *Hardcastle, SAJCC July 2008

  10. Operative Technique

  11. Zone 1 • Drape widely • If in doubt – sternotomy • High ANT for proximal L-SCA • Beware of the BCV • Oversew • Get proximal control

  12. Zone 1 • Access to: • BCA • L-CCA • L-SCA; actually better than HLAT • Heart • Oesophagus below T1 better via R-Thoracotomy, also trachea/bronchi

  13. Zone 2 • Standard neck incision • Drape for extensions • Position is everything • Good haemostasis • Loop readily • Use the plains

  14. Vascular injury • Proximal and distal control • Heparinise • Debride and mobilise • Can often repair primarily • Vein grafts are best • PTFE is acceptable conduit • Veins can be readily ligated

  15. Aero-digestive injury • Repair true oesophagus – below C6 • Pharynx can be safely drained • Avoid trachy with oesophagus injury • Muscle interposition for combined tracheal and oesophageal injury • Single layer absorbable repairs • Drain – (not closed suction) for 8-10 days; place intra-op NGT • Trachea – interrupted sutures; air tight

  16. Zone 3 • Tiger country! • I don’t like the jaw transection! • Try muscle releases first • Bite-block in mouth gives extra space • High Carotid – repair distal first • Consider ligation if good back-pressure • Watch out for the hypoglossus – at the carotid bifurcation

  17. Other options • Endovascular therapy stents and coils Requires catheter expertise or ready access to interventional radiology BJS 2003: 1516 / J Vasc Surg 2008: 739 / Eur J Vasc Endovasc Surg 2000: 489 & 2008: 56 / J Endovasc Ther 2001: 529

  18. Closure • Sternotomy standard closure • Leave a mediastinal drain • Neck • Close the platysma • Close the skin • Drain via a separate site • Trachy via a separate incision if needed

  19. Post-operative care • ICU only if intubated / trachy • Mobilize early • LMWH post-op • Contrast study on D5 - 7 • NGT for early feeding • Extubate around D3 if trachea repaired • Remove drains once tolerating oral diet • Beware swallowing incoordination is common • Only 3 doses of prophylactic AB

  20. Outcome • Non-operative • Minimal missed injury, seldom clinically significant • Aerodigestive injury • Most will heal; leaks can be controlled fistula • Time to repair determinant • Vascular • Repair within 24 hours good outcomes* *Du Toit et al J Vasc Surg 2003: 257

  21. Conclusions • Penetrating injury to the neck can be challenging • May be unfamiliar territory to many General Surgeons • Know the approaches • Know the anatomy • Most patients will do well if principles followed

  22. ?

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