Department of surgery Songkhla hospital

Superficial cervical fascia - platysma Deep cervical fascia

◦Investing : sternocleidomastoid muscle, trapezius muscle

◦Pretracheal : larynx, trachea, thyroid gland, pericardium

◦Prevertebral : prevertebral muscles, phrenic nerve, brachial plexus, axillary sheath

◦Carotid sheath : carotid artery, internal jugular vein, vagus nerve

Wounds that penetrate the platysma must be further evaluated

The major vascular and aerodigestive structures in the neck are located in the anterior triangle, and all are deep to the platysma

Penetrating injuries to the posterior triangle should raise concern about trauma to the cervical spine and spinal cord

Zone I is the thoracic inlet from the sternal notch to the cricoid cartilage

Zone II is the midportion of the neck from the cricoid cartilage to the angle of the mandible

Zone III extends from the angle of the mandible to the base of the skull

Zone I◦ Contains the subclavian arteries and veins, the

dome of the pleura, esophagus, great vessels of the neck, recurrent nerve, trachea

Zone II◦ Contains the larynx, pharynx, base of tongue,

carotid artery and jugular vein, phrenic, vagus, and hypoglossal nerves

Zone III◦ Contains the internal and external carotid

arteries, the vertebral artery, and several cranial nerves

Does the patient require emergent airway protection?

What is the best approach and technique for airway protection?

Airway compromise (eg, respiratory distress, severe hemorrhage, extensive or sucking neck wound, shock)

Definite airway should be perform such as orotracheal tube or surgical airway

Surgical airway is recommended if significant trauma or obstruction above the larynx or if anatomy is sufficiently distorted and airway cannot be identified

Significant bleeding or hematoma Hemoptysis Subcutaneous emphysema Bruit or thrill Neurologic deficit Distorted neck anatomy Stridor Difficulty or pain when swallowing secretion Abnormal voice especially hoarseness(hot

potato voice)

Method Oral & nasal intubation with or without endoscopic

guidance or muscle relaxants Surgical airway

Surgical airway◦Cricothyrotomy (life saving procedure ,

temporary airway) ◦Tracheostomy

Zone I injuries with concomitant thoracic injuries◦pneumothorax◦hemopneumothorax◦tension pneumothorax

Bleeding should be controlled by pressure Do not clamp blindly or probe the wound

depths The absence of visible hemorrhage does not

rule out Two large bore IVs

Thorough head and neck exam using palpation and stethoscope to search for thrills and bruits

Neuro exam: mental status, cranial nerves, and spinal column

Examine the chest, abdomen, and extremities

Be sure to examine the back of the patient as unsuspected stab or gunshot wounds have been missed here

Don’t blindly explore wound or clamp vessel

Unstable patient Immediate transfer to the OR

Stable patient◦Mandatory exploration◦Selective approach

Vascular injury ShockHematoma

Hemorrhage Pulse deficit Neurologic deficit Bruit or thrill in neck Laryngotracheal injury Subcutaneous emphysema

Airway obstruction Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia

Pharynx/esophagusinjurySubcutaneous emphysema Hematemesis Dysphagia or odynophagia

X-Rays◦Pneumothorax or hemothorax◦retropharyngeal air or

pneumomediastinum, suggests esophageal injury

CT neck◦A multidetector helical CT scan (MDCT) is often the first study obtained because it can detect laryngotracheal, vascular, and esophageal injuries simultaneously and rapidly

Esophagography◦All penetrating neck injuries due to high incidence of occult esophageal injuries

Endoscopy◦If swallow (-), enhances sensitivity for penetrating esophageal injury

CT-Angiogram◦The sensitivity and specificity of CT-A for

detecting significant vascular wounds in the neck approaches nearly that of standard angiography

Angiography◦Angiography demonstrates sensitivity

and specificity of close to 100 percent and has been considered the gold standard in stable patients

Endoscopy or laryngoscopy◦alternatives for the diagnosis of LT

trauma