Neck Trauma Flashcards
Positioning/prep for neck trauma OR.
Prep ears to mid-thigh. Include b/l groins and prep down to table on b/l chests.
Incision/exposure for neck trauma.
Standard: ant SCM
Bilateral or known laryngeal/tracheal injury: collar
Zone I: supraclavicular
Zone III: +/- subluxation or resection mandible to access distal carotid.
Hard signs of neck injury.
Brisk bleeding, expanding/pulsatile hematoma, massive subcutaneous emphysema.
Soft signs of neck injury.
Dysphagia/odynophagia, dysphonia/voice changes, MILD hemoptysis/hematemesis, widened mediastinum, pneumomediastinum
Indications to screen for blunt cerebrovascular injury.
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
Zone I boundaries and contents.
Clavicles and sternal notch TO cricoid cartilage.
Includes: trachea, great vessels, esophagus, thoracic duct, lung apices, thyroid, brachial plexus
zone I injury exposure
sternotomy
Zone II boundaries and contents.
Cricoid cartilage to angle of the mandible.
Includes: common carotid, vertebral artery, jugular vein, esophagus, pharynx, trachea, larynx, vagus and recurrent
zone II exposure
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
Zone III boundaries and contents.
Angle of the mandible to base of the skull.
Includes: distal internal carotid (MC BCVI), vertebral artery, jugular vein, hypopharynx.
Posterior bleeding in neck exploration?
Vert aa injury - just ligate
stroke rate in carotid aa ligation
20%
How to repair an IJ injury (if can avoid ligation).
Lateral venorrhaphy with postop anticoagulation.
Esophageal injury operative technique.
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.
Indication for NOM for esophageal injury.
Small contained perforations with limited leakage. NPO, TPN or G tube feeds.
indication for tracheobronchial injury tx?
if >1/3 of tracheal diameter, 2 wks of air leak, large air leak with resp compromise, or can’t get lung up at all … 90% are within 1 cm of carina!
Tracheal injury operative technique.
Primary repair in ONE layer with monofilament absorbable suture.
Thyroid injury operative technique.
Debride, ligate, and drain (avoid lobectomy, total resection) – and monitor for hypopit.
Thoracic duct injury operative technique.
Just ligate.
Submandibular gland or parotid tail (no duct injury) injury operative technique.
Debride and place drain.
Blunt cerebrovascular injury management option.
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
Contents of the carotid sheath?
Carotid aa, internal jugular v, CN X, ansa cervicalis (innerv. infrahyoid mm/”strap” mm, C1-3)
What are the strap muscles?
Sternohyoid, sternothyroid, thyrohyoid and omohyoid muscles. They depress the hyoid bone to allow for speech/swallow.
Denver criteria? (to get a CTA in BCVI)
- 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)
MC site for BCVI?
Distal internal carotid artery
MC treatment for BCVI?
Antiplatelt therapy»_space; endovascular intervention for PSA or AVF
Gateway structure to carotid bifurcation?
Common facial vein
Gateway structure for great vessels during sternotomy?
Innominate vein.
BIFFL stages for BCVI
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
completely occluded carotid tx
plavix or heparin
partially occluded carotid tx (trauma)
covered stent if sx
plavix or heparin if asx with a repeat CTA before DC
carotid AVF, PSA, sx-ic partially occluded dissection?
covered stent
isolate cervical seat belt sign - CTA?
naur
where can reimplant RLN
into the cricoarytenoid msucle
