Penetrating Neck Trauma

Question 1

What are potential causes of life-threatening airway injuries?

Answer 1

Tracheal or cartilaginous rupture, soft tissue compression from adjacent arterial injury, or active hemorrhage into the tracheal-bronchial tree due to a vascular airway fistula

Question 2

What are signs and symptoms of acute airway challenges?

Answer 2

Hemoptysis, stridor, hoarseness, subcutaneous air, air hunger, or refusal to lie down

Question 3

What type of intubation is advised when bleeding obscures the hypopharynx?

Answer 3

Fiber-optic nasotracheal intubation by experienced personnel.

Question 4

Why should oral intubation be used when severe nasal fractures or lower forehead fractures are present?

Answer 4

To prevent injury through a fractured cribriform plate into the frontal lobe

Question 5

What should be done when both oral and nasal routes of intubation are compromised?

Answer 5

Proceed directly to a coniotomy (cricothyroidotomy) or, in less urgent situations, a rapid tracheostomy

Question 6

Priorities in Care of Penetrating Neck Wounds

Answer 6

1. Emergency airway control
2. Hemostasis for active bleeding (anterior or posterior)
3. Urgent operation for nonbleeding life-threatening wounds
4. Urgent diagnosis for patients who are stable
5. Decision to explore or observe stable patients
6. Exposure of internal organs
7. Specific treatment of the injured organs

Question 7

What does nonpulsatile bleeding typically indicate?

Answer 7

major venous injury

Question 8

How can nonpulsatile venous bleeding be controlled?

Answer 8

applying direct digital pressure over the suspected venous perforation.

Question 9

What does pulsatile bleeding indicate?

Answer 9

An arterial injury

Question 10

How can pulsatile arterial bleeding be controlled in the field?

Answer 10

By placing a gloved finger through the penetrating wound to palpate and apply pressure to the origin of the arterial perforation, to OT
until dissection reaches the injured artery

Question 11

What are “hard signs” that indicate the need for an urgent operation in a trauma patient?

Answer 11

A pulsatile hematoma > Arterial injury
continued external oozing
cervical crepitus > airway/Trach/Esophag injury
hoarseness
air bubbles in the wound
dyspnea
stridor
air hunger
or large soft tissue wounds requiring surgical closure

Question 12

What are “soft signs” that may indicate a less severe, but still concerning, injury in a trauma patient?

Answer 12

Continued superficial bleeding
history of major bleeding before arrival
blood-streaked sputum
and cervical swelling

Question 13

What is the first step in the urgent investigation of a neck injury?

Answer 13

-physical examination of the neck, including an intraoral examination for blood or mucosal injury of the pharynx or hypopharynx
-chest auscultation and examination for tracheal deviation > pneumothorax or mediastinal shift
-endoscopic examination > small injuries to the trachea or esophagus

Question 14

What imaging modality is typically used to identify an arterial injury?

Answer 14

CT angiography, although formal arteriography may be necessary if CT angiography is inconclusive

Question 15

What type of injuries are most surgeons likely to explore in penetrating zone 2 injuries?

Answer 15

Injuries with evidence of organ injury
hematoma
continued oozing
or suspicion of a tracheal or esophageal injury.

Question 16

What is the preferred incision for exploring most penetrating neck wounds?

Answer 16

An ipsilateral incision along the anterior border of the sternocleidomastoid (SCM) muscle

-Through the platysma into the deeper planes
-trachea and thyroid gland retracted anteriorly
-neurovascular bundle and esophagus displaced posteriorly
-Expose the tracheal esophageal groove
-identify when further dissection is needed
-Superficial crossing veins are divided and ligated, as is the omohyoid muscle

Question 17

How can access to the internal carotid artery at the base of the skull (zone 3 injury) be facilitated for repair?

Answer 17

By detaching the mandible posteriorly to the angle and subluxating it anteriorly

Question 18

What incision is used to expose zone 1 structures in the thoracic outlet during surgical repair?

Answer 18

An incision extended inferiorly as a median sternotomy.

Question 19

What structures can be accessed through a median sternotomy in zone 1 injuries?

Answer 19

The trachea
innominate artery
left common carotid artery
subclavian artery
subclavian vein
innominate vein,
superior vena cava

Question 20

How can access to the subclavian artery just beyond its origin from the aortic arch be achieved?

Answer 20

extending the median sternotomy laterally in the left fourth interspace, dividing the clavicle, and rotating the left anterior chest wall as a Ravitch flap

Question 21

How is access gained to the subclavian artery posterior to the clavicle?

Answer 21

By resecting the medial half of the clavicle, providing excellent exposure to the subclavian artery and vein

Question 22

What is the most common cause of non–life-threatening hemorrhage from penetrating neck wounds?

Answer 22

Venous injuries.

Question 23

How should small veins, such as the external jugular vein, be managed in venous injuries?

Answer 23

best ligated.

Question 24

How can the internal jugular vein be repaired if the wound involves less than 30% of its circumference?

Answer 24

It can be repaired primarily using a fine, nonabsorbable suture

Question 25

What should be done if the internal jugular vein has large through-and-through wounds?

Answer 25

vein should be ligated, which is generally well-tolerated

Question 26

Where should intraoperative dissection begin during neck exploration for suspected arterial injury

Answer 26

Above the clavicle in the neurovascular complex to free the proximal common carotid artery

Question 27

How are small arterial injuries from pellet wounds typically repaired?

Answer 27

With a single 5-0 nonabsorbable suture for each pellet hole

Question 28

What is the typical treatment for through-and-through low-velocity gunshot wounds to the carotid artery?

Answer 28

Resection of the injured segment followed by end-to-end anastomosis using a running 5-0 nonabsorbable suture

Question 29

How are more extensive carotid artery injuries from high-velocity missiles treated?

Answer 29

By resection of a longer segment of the artery and replacement with a reverse saphenous vein graft.

prosthetic grafts > Avoided
Unless no other options

Question 30

How are injured branches of the external carotid artery in zone 2 best managed?

Answer 30

best ligated

Question 31

What is done if the proximal internal carotid artery is completely disrupted?

Answer 31

The intact external carotid artery can be swung over and anastomosed to the distal internal carotid artery to maintain cerebral perfusion

Question 32

What may be the best option for managing disruption of the internal carotid artery at the base of the skull?

Answer 32

Distal ligation, particularly if the patient has no preoperative neural deficit and there is good back bleeding.

Question 33

What do the authors recommend for patients with preoperative neurologic deficits and carotid artery injury?

Answer 33

repair, as brain ischemia often results in diffuse cerebral edema without hemorrhage on postmortem examination

Question 34

What is the most common cause of vertebral artery injury?

Answer 34

Gunshot injury.

Question 35

How is vertebral artery injury typically diagnosed?

Answer 35

Suspected based on a CT angiogram and confirmed by angiography.

Question 36

How is vertebral artery injury treated?

Answer 36

By proximal ligation at its origin from the subclavian artery, and if necessary, distal ligation approaching the artery between vertebrae C1 and C2.

Question 37

How is the esophagus exposed during surgery for an esophageal injury?

Answer 37

anterior sternocleidomastoid (SCM) approach, freeing the esophagus from the trachea anteriorly and the prevertebral fascia posteriorly.

Question 38

How does the presence of a nasogastric tube aid in esophageal surgery?

Answer 38

facilitates digital identification and safe mobilization of the esophagus

Question 39

How are most unilateral stab wounds to the esophagus repaired?

Answer 39

In two layers
full-thickness mucosa and muscular layers for inner layers
and the outer layer uses tension-free interrupted 4-0 permanent sutures.

Question 40

What can be done if bilateral esophageal perforations are present?

Answer 40

The esophagus can be rotated to repair the contralateral side
or the contralateral perforation can be closed from an intraluminal approach.

Question 41

What should be done following the closure of an esophageal perforation?

Answer 41

drain should be left in place, and the drainage should be monitored for amylase

Question 42

How are esophageal cutaneous fistulas managed if they occur?

Answer 42

Nasogastric tube feedings are instituted, and the fistula usually closes over 3 weeks

Question 43

Why is it important to leave the esophageal drain in place when a fistula occurs with vascular injuries?

Answer 43

To prevent unevacuated esophageal leakage, which could compromise the repair of the vascular injury

Question 44

How are perforations of the pharynx and hypopharynx often suspected?

Answer 44

blood is seen on deep oral examination.

Question 45

How are pharyngeal and hypopharyngeal perforations typically repaired?

Answer 45

primary closure using full-thickness inverted absorbable sutures for hemostasis and secure closure.

Question 46

How can the trachea be freed during surgery using the anterior SCM approach?

Answer 46

-dissection in the tracheal-esophageal groove

Question 47

How are posterior tracheal perforations typically repaired?

Answer 47

running or interrupted 3-0 absorbable sutures, with the knots tied on the outside

Question 48

What should be considered when identifying a posterior tracheal perforation?

Answer 48

possibility of an associated anterior esophageal perforation

Question 49

How are perforations of the anterior trachea repaired?

Answer 49

Sutures are placed in the interspaces above and below the perforated tracheal rings, with knots tied on the outside.

Question 50

How are cartilaginous tracheal injuries treated?

Answer 50

sutures heavy enough to go through the cartilage for apposition, though some cartilaginous injuries are allowed to heal by second intent

Question 51

What is the purpose of adding a tracheostomy in tracheal injury repair?

Answer 51

protect the airway and reduce airway resistance from the intact glottis

Question 52

Where is the preferred location for high tracheostomy insertion when the injury is distal in the trachea

Answer 52

At the second tracheal ring

Question 53

How is hemostasis typically obtained when the injured portion of the thyroid gland is located lateral to the trachea?

Answer 53

With simple sutures or electrocoagulation

Question 54

What is the recommended treatment for a thyroid injury that extends through the thyroid into the trachea

Answer 54

The injured portion of the thyroid is best resected.

Question 55

How can the thyroid be managed to facilitate primary tracheal repair when it is injured?

Answer 55

The thyroid may be divided at the isthmus and rotated off the trachea.

Question 56

How are injuries to the recurrent laryngeal or vagus nerve typically managed if caused by a gunshot wound?

Answer 56

nerve is unlikely to be completely severed and is best left alone to regenerate over time.

Question 57

How should a completely severed recurrent laryngeal or vagus nerve, due to a stab wound, be managed

Answer 57

primary approximation using fine absorbable sutures is recommended

Question 58

How are injuries to the thoracic duct recognized during surgery?

Answer 58

-presence of lymph within the operative field.
-freed up at its insertion into the venous angle, isolated, divided, and ligated at each end.