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 - just ligate

Question 12

stroke rate in carotid aa ligation

Answer 12

20%

Question 13

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

Answer 13

Lateral venorrhaphy with postop anticoagulation.

Question 14

Esophageal injury operative technique.

Answer 14

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 15

Indication for NOM for esophageal injury.

Answer 15

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

Question 16

indication for tracheobronchial injury tx?

Answer 16

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!

Question 17

Tracheal injury operative technique.

Answer 17

Primary repair in ONE layer with monofilament absorbable suture.

Question 18

Thyroid injury operative technique.

Answer 18

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

Question 19

Thoracic duct injury operative technique.

Answer 19

Just ligate.

Question 20

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

Answer 20

Debride and place drain.

Question 21

Blunt cerebrovascular injury management option.

Answer 21

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 22

Contents of the carotid sheath?

Answer 22

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

Question 23

What are the strap muscles?

Answer 23

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

Question 24

Denver criteria? (to get a CTA in BCVI)

Answer 24

• 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 25

MC site for BCVI?

Answer 25

Distal internal carotid artery

Question 26

MC treatment for BCVI?

Answer 26

Antiplatelt therapy&raquo_space; endovascular intervention for PSA or AVF

Question 27

Gateway structure to carotid bifurcation?

Answer 27

Common facial vein

Question 28

Gateway structure for great vessels during sternotomy?

Answer 28

Innominate vein.

Question 29

BIFFL stages for BCVI

Answer 29

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

Question 30

completely occluded carotid tx

Answer 30

plavix or heparin

Question 31

partially occluded carotid tx (trauma)

Answer 31

covered stent if sx
plavix or heparin if asx with a repeat CTA before DC

Question 32

carotid AVF, PSA, sx-ic partially occluded dissection?

Answer 32

covered stent

Question 33

isolate cervical seat belt sign - CTA?

Answer 33

naur

Question 34

where can reimplant RLN

Answer 34

into the cricoarytenoid msucle