Neck Trauma

Question 1

Positioning/prep for neck trauma OR.

Answer 1

Prep ears to mid-thigh. Include b/l groins and prep down to table on b/l chests.

Question 2

Incision/exposure for neck trauma.

Answer 2

Standard: ant SCM
Bilateral or known laryngeal/tracheal injury: collar
Zone I: supraclavicular
Zone III: +/- subluxation or resection mandible to access distal carotid.

Question 3

Hard signs of neck injury.

Answer 3

Brisk bleeding, expanding/pulsatile hematoma, massive subcutaneous emphysema.

Question 4

Soft signs of neck injury.

Answer 4

Dysphagia/odynophagia, dysphonia/voice changes, MILD hemoptysis/hematemesis, widened mediastinum, pneumomediastinum

Question 5

Indications to screen for blunt cerebrovascular injury.

Answer 5

Denver criteria: Neuro abnormality, epistaxis, GCS <8, petrous bone fracture, diffuse axonal injury, C1-C3 fx, fracture through transverse foramen, C-spine fx with subluxation/rotation, Lefort II and III fx.

not cervical seat belt alone

Question 6

Zone I boundaries and contents.

Answer 6

Clavicles and sternal notch TO cricoid cartilage.
Includes: trachea, great vessels, esophagus, thoracic duct, lung apices, thyroid, brachial plexus

Question 7

zone I injury exposure

Answer 7

sternotomy

Question 8

Zone II boundaries and contents.

Answer 8

Cricoid cartilage to angle of the mandible.
Includes: common carotid, vertebral artery, jugular vein, esophagus, pharynx, trachea, larynx, vagus and recurrent

Question 9

zone II exposure

Answer 9

incision anterior to SCM

divide platysma muscle and move SCM laterally
identify medial border of IJ
identify facial V and ligate (overlies carotid bifurc)
move IJ laterally
carotid artery exposed

Question 10

Zone III boundaries and contents.

Answer 10

Angle of the mandible to base of the skull.
Includes: distal internal carotid (MC BCVI), vertebral artery, jugular vein, hypopharynx.

Question 11

Posterior bleeding in neck exploration?

Answer 11

Vert aa injury

Question 12

How to repair an IJ injury (if can avoid ligation).

Answer 12

Lateral venorrhaphy with postop anticoagulation.

Question 13

Esophageal injury operative technique.

Answer 13

Debride and close in TWO layers (extend myotomy to see all of mucosal injury) with absorbable suture on mucosa – buttress repair – closed suction drain – contrast study prior to drain removal.

Need distal feeding

Widely drain if cannot find defect.

Question 14

Indication for NOM for esophageal injury.

Answer 14

Small contained perforations with limited leakage. NPO, TPN or G tube feeds.

Question 15

Tracheal injury operative technique.

Answer 15

Primary repair in ONE layer with monofilament absorbable suture.

Question 16

Thyroid injury operative technique.

Answer 16

Debride (avoid lobectomy, total resection) – and monitor for hypopit.

Question 17

Thoracic duct injury operative technique.

Answer 17

Just ligate.

Question 18

Submandibular gland or parotid tail (no duct injury) injury operative technique.

Answer 18

Debride and place drain.

Question 19

Blunt cerebrovascular injury management option.

Answer 19

Operative if lesion accessible.
Anticoagulate with heparin gtt (40-50) [hep gtt at 15U/kg without bolus] then warfarin or ASA x6 mos post-injury

Question 20

Contents of the carotid sheath?

Answer 20

Carotid aa, internal jugular v, CN X, ansa cervicalis (innerv. infrahyoid mm/”strap” mm, C1-3)

Question 21

What are the strap muscles?

Answer 21

Sternohyoid, sternothyroid, thyrohyoid and omohyoid muscles. They depress the hyoid bone to allow for speech/swallow.

Question 22

Denver criteria? (to get a CTA in BCVI)

Answer 22

• Severe cervical hyperextension/rotation or hyperflexion.
• Hanging mechanism
• Neurological exam not explained by brain imaging
• DAI
• Skull base fractures involving foramen lacerum
• Horners syndrome
• Lefort II or III facial fx
• C-spine fx esp C1-C3
• Epistaxis from suspected arterial source after trauma
• Blunt head trauma with GCS < 8
• Cervical bruit, hematoma

(not isolated seat belt cervical)

Question 23

MC site for BCVI?

Answer 23

Distal internal carotid artery

Question 24

MC treatment for BCVI?

Answer 24

Antiplatelt therapy&raquo_space; endovascular intervention for PSA or AVF

Question 25

Gateway structure to carotid bifurcation?

Answer 25

Common facial vein

Question 26

Gateway structure for great vessels during sternotomy?

Answer 26

Innominate vein.

Question 27

BIFFL stages for BCVI

Answer 27

grade I: minimal luminal irregularity or intramural hematoma/dissection with <25% luminal narrowing

grade II: intramural hematoma/dissection with ≥25% luminal narrowing, intraluminal thrombus, or raised intimal flap

grade III: pseudoaneurysm

grade IV: occlusion

grade V: transection with free extravasation