Neck Flashcards
Discuss zone 1 of the neck and contents (10)
Zone 1 Extends superiorly from the sternal notch and clalicle to the cricoid cartilatge
Contents
- Proximal common carotid artery
- vertebral artery
- subclavian artery
- major vessels of upper mediastinum
- apices of the lung
- oesophagus
- trachea
- thyroids
- thoracic duct
- spinal cord
Discuss zone 2 of the neck and contents `(10)
Zone 2 extends from the cricoid cartilage to the angle of the mandible
Contents
- carotid artery
- vertebral artery
- larynx
- trachea
- oeosphagus
- pharynx
- jugular vein
- vagus snerve
- recurrent laryngeal nerve – vocal cords
- spinal nerve
Discuss zone 3 of the neck and its contents (6)
Zone 3 extends from the angle of the mandible to the base of the skull
Contents
- distal carotid artery
- vertebral artery
- distal jugular vein
- salivary and parotid glands
- cranial nerves 9-`12
- spinal cord
Discuss the fasical layers of the neck
Two layres
-Superficial layer covers the platysma muscle and is located just below the skin
The deep layer is divided into three parts
1) the investing layer surrounds the neck and splits to encase the sternocleridomastoid and trap
2) the pretracheal layer adheres to the cricoid and thyroids cartilages and travels deep to the sternum to insert into the pericardium
3) The prevertebral layer envelopes the cervical prevertebal muscles and extends to form the axillary sheath in which the subclavian artery runs
The pretracheal layer is important because of its connection of the neck to the anterior mediastinum. Missed aerodigestive injury can cause mediastinitis due to this anatomic continuity,
Injury to the platysma should raise questions about injury to deep structures
Discuss broadly the four groups of neck injury patients
1) those who are HD unstable
2) Those are HD stable with hard signs
3) Those who are HD stable with soft signs
4) asymptomatic patients
1 and 2 likely need OR for exploration
Diagnositic testing is indicated in all who who soft or hard signs
List soft signs for penetrating neck injury
Minor haemoptysis Haematemesis Dysphonia, dysphagia Subcutaneous or mediastinal air Nonexpanding haematoma Oropharyngeal bleeding Neurological findings Proximity to the wound
List hard signs of penetrating neck injury (9)
Rapidly expanding pulsatile haematoma Massive haemoptysis Air bubbling from wound Severe haemorrhage Shock not responding to fluids Decreased or absent radial pulse Vascular bruit or thrill Stridor/hoarseness or airway compromise Cerebral ischaemia \+- massive subcut emphysema
Discuss management of neck trauma in general
A: highest priority– BVM can be harmful as can force air into injured tissue planes – resulting in massive subcut emphysema and subsequent airwya distortion or rarely air embolus.
ETT with RSI remains standard with inline stabilization – relative contraindication include significant anatomical disruption of the face or neck massive haematemesis or concern that RSI will not succeed- If time allows fibreoptic laryngscopy may be preferable – Dont use nasal intubation due to false passages and poor outcomes – cric if needed
B: As standard with attention for pneumothorax in zone 1 injuries
- Indication for resuscitiative thoracotomy is CPR for less than 15 minutes wiht penetrating neck trauma or less than 10 minutes of CPR with any blunt trauma
c: direct pressure without occlusion of airway
D: Attention to c-spine
G: placement of NGT is relatively contrainicated in patient with penetrating neck trauma
Discuss venous or artieral air embolism in neck trauma
Venous air embolism causes profound shock or arrest unresponsive to fluids or thoracotomy.
As the circulatory pressure in most arteries and veins is greater than atmospheric pressure an embolus does not often happen when a vessel is injured. In veins above the heart such as in the head and neck this pressure is often lower than the atmosphere with potentional risk for air embolism
Placing the patientin a head down left lateral will cause intracardiac air to accumulate in the apex of the right ventricle. If shock still persist aspiration of air form the right ventricle can eb attempted either via US or under direct vision after thoracotomy
Neurological sequela or any otherwise unexplained stroke like syndrome should prompt consideration of arterial air embolis, If arterial embolus is suscpected stroke can cause cerebral oedema and brain protective measures should be undertaken
Discuss pharyngoesophaegeal trauma (epi, signs, ix, mx)
Rare usually associated with penetrating trauma involving the cervical segement. Injury from blunt trauma is associated with hyperextension or cervical fractures
Early identification is necessary as can lead to bacteraila contamination and mediastinitis
Air leaking out through the owund site is the most compelling indicator of an underlying oesophageal or airway injury
Investigation
- contrast oesophagraphy can be used with a co-operative patient. Typically water soluble contrast is used as barium is more dangerous when extravasation occurs
- CTA without oral contrast is currently not supported by literature– non oral contrast CT depends on visualistaion of idnirect signs such as paraeosophageal air or fluid, wall thickening or oeedmea.
If suspected broad spectrum AB with anerobic coverage (piptaz) should be used and patient should be kept NBM
Emergent theatre is likley necessary
Discuss laryngotracheal trauma (epi, anatomy)
Account for only 1% of neck trauma but a high percentage of immediate morality
The cricoid cartilage is the only complete ring int he larynx – fractures can lead to daeth through acute airway obstruction
The degree of airway obstruction after blunt trauma to the larynx is inversely related to the degree of cartilage calcification – children are therefore at the highest risk of respiratory compromise after injury
Pain on movement of the toungue or rotation of the neck may indicate damage to the hyioid bone
Discuss laryngotracheal trauma investigations
Laryngoscopy or flexible nosopharyngoscopy allows direct evaluation of laryngeal integrity. – Usually is well tolerated with appropriate local anaethetics – preparation for emergeny intubation should always be perform prior to laryngoscopy
CT has almost 100% sensitivity – less useful for detection of mucosal perforation degloving injyuries or the cartilage and some types of minor trauma especially in the peadiatric population
Ultrasound can be considered as a bedside test to detect blunt laryngotracheal injuries such as laryngotracheal separation.
Discuss management of laryngotracheal trauma
Early laryngoscopy to identify injury with low threshold for intubation. – Ideally awake fibreoptic intubation is the choice
If not available awake video intubation
If not available double set up – sinlge attempt by best provider than surgical access
Most patient will be able to be intubated normally however it is not possible to visualise the airway inferior to the cords unless a flexi scope is used. Tube must be placed gently and guided down the airway with the least friction possible to reduce further injury. (completing laryngeal tracheal seperation or false passage)
If seperation has occured – proximal intubation as above can be tried – if surgical option tracheal hooks can be used to retrieve the distal segment.
Discuss vascular injury (blunt)
Half of all patient with dissection from blunt trauma are neurologically asymptomatic. – if present carotid injuries cause either transient of fixed contraleratl sensory or motor deficitis, aphasia dysphasia and Horners syndrome.
Vertebral injuries can cause ataxia vertigo, emesis and visual field deficits. –
If present these symptoms are often delayed. Most develop 10-72 hours post injury with a median of 12.5 hours.
Discuss Western Trauma Association criteria for imaging of blunt cerebrovascular imaging
Symptomatic
- Arterial haemorrhage form the neck mouth, nose or ears
- Large or expanding cervical haemartoma
- Cervical bruit in patient <50 years
- Focal neuroglocail deficit
- evidence of cerebrla infarct
- Neurolgocial deficit incongruous with CT/MRI
Asymptomatic
-Cervical hyperextension or flexion with rotation
- Direct cervical trauma
-intraoral trauma
-basilar skull fracutre involving the carotid canal
-Lefort 2 or 3
- head injury with GCS <6
Fracture of c1-3
-vertebral body or transverse foramen fracutre
-hanging with cerebral anoxia
-seatbelt sign of clothesline injury with significant cervical pain, swelling
