Carotid, jugular, and vertebral vessel injuries

Question 1

Steps to expose the carotid artery?

Answer 1

-incision on anterior border of SCM from clavicular head to retromandibular area
-lateral rectraction of SCM
-division of omohyoid and common facial vein
-preserve hypoglossal and vagus nerves

Question 2

Positioning and prep steps to remember for exposure.

Answer 2

-arms tucked
-shoulder roll
-head rotated to contralateral side (if no c-spine injury suspected)
-prep neck, torso, and groin in case sternotomy or saphenous vein harvest needed

Question 3

What are the borders of neck zone 1?

Answer 3

inferior aspect of cricoid cartilage to thoracic outlet

Question 4

How do you access zone 1 injuries?

Answer 4

sternotomy or anterior thoracotomy

Question 5

What are the borders of neck zone 2?

Answer 5

cricoid cartilage to the angle of the mandible

Question 6

How do you access zone 2 injuries?

Answer 6

anterior border of SCM

Question 7

What critical structures are found in zone 2?

Answer 7

-jugular veins
-distal common carotid arteries and bifurcations
-proximal external and internal carotids
-vertebral arteries
-thyroid gland
-larynx
-proximal esophagus
-spinal cord
-vagus, phrenic, recurrent laryngeal nerves

Question 8

What adjuncts can/should be used to help identify injuries in a HD normal patient with a zone 2 injury?

Answer 8

-CT angio
-bronchoscopy
-laryngoscopy
-EGD

Question 9

What muscle is divide to expose the carotid artery?

Answer 9

omohyoid

Question 10

What critical structure is typically found just deep to the facial vein?

Answer 10

carotid bifurcation

Question 11

What percent of the population does not have an intact Circle of Willis?

Answer 11

15%

Question 12

What are the borders of neck zone 3?

Answer 12

bony structures of skull and mandible

Question 13

What structures are found in zone 3?

Answer 13

-pharynx
-vertebral arteries
-distal internal carotid arteries

Question 14

How is hemorrhage controlled for most zone 3 injuries?

Answer 14

endovascular

Question 15

What are some examples of blunt mechanisms that can cause vertebral artery injuries?

Answer 15

-basilar skull fx
-axial injuries
-ligamentous disruption
-direct blow to the neck
-chiropractic manipulation
-yoga exercises
-central line insertion
-angiography
-spine operations

Question 16

Which part of the vertebral artery is NOT protected by the cervical vertebrae?

Answer 16

V1

Question 17

What incision is used to expose the vertebral arteries at their origin off the subclavian?

Answer 17

transverse supraclavicular

Question 18

What incision is used to expose the distal portion of V1?

Answer 18

vertical anterior cervical incision
-along anterior border of SCM
-retract carotid sheath medially
-retract scalene fat pad laterally to expose anterior scalene muscle
-retract or divide anterior scalene

Question 19

What is one way to temporize bleeding from a stab wound in the posterior triangle of the neck? What has been injured?

Answer 19

-V2 injury
-place a foley balloon in the wound to temporize until endovascular repair can be performed

Question 20

What are the borders of V1 of the vertebral artery?

Answer 20

origin from subclavian to the transverse process of 6th cervical vertebrae

Question 21

What are the borders of V2 of the vertebral artery?

Answer 21

runs intraosseous from TP of C6 to C2

Question 22

What are the borders of V3 of the vertebral artery?

Answer 22

runs intraosseous from C2 to base of skull

Question 23

What are the borders of V4 of the vertebral artery?

Answer 23

intracranial from foramen Magnum