Trauma - Neck, Larynx Flashcards
(42 cards)
Discuss the initial basic approach to trauma
- ABCDE
- GCS (E4, V5, M6)
- C-spine immobilization and X-ray
Describe the zones of the neck with respect to blunt/penetrating neck trauma
- Zone 1: From the clavicle to the inferior border of the cricoid
- Zone 2: Inferior border of cricoid to the angle of the mandible
- Zone 3: Above the angle of the mandible to the level of the skull base
Bailey’s uses inferior border of cricoid, resident trauma manual uses horizontal line dividing cricoid
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How are neck injuries generally classified? Name two different classification ways.
- By Zone (I/II/III)
- Penetrating vs. Non-penetrating
Penetrating = passes through platysma
Non-penetrating = does not violate platysma
How are penetrating neck injuries classified? 2
Classified based on velocity:
- Low-Velocity Penetrating Neck Trauma (LVPNT)
- < 610m/s (< 2000feet/second)
- Examples: stab wounds, handgun wounds - High-Velocity Penetrating Neck Trauma (HVPNT)
- > 610m/s (>2000 feet/second)
- Examples: Rifle wounds, wounds from bombs/Improvised explosive devices (IEDs)/grenades
Note: Bailey’s uses < 1000ft/sec and > 10000ft/s
What determines the kinetic energy imparted on tissues during traumatic penetrating injury? 4 what is highest energ?
KE = 1/2 M (V1-V2)^2
KE = Kinetic energy of the missile
M = Missile mass
V1 = Entry velocity
V2 = Exit velocity
The highest kinetic energy is thus associated with a heavy projectile with a high entry velocity and an exit velocity of 0 (that is, it doesn’t leave the body)
- Examples of these would include expanding or explosive bullets
What 2 mechanisms that mediate gunshot wound injury?
- Direct tissue injury
- Temporary cavitation (creation of a pulsating temporary cavity surrounding the bullet path)
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What are the indications for vascular evaluation (e.g. Angiography) in penetrating wounds to the face? 2
P’s mnemonic:
1. Proximity to major vascular structures
2. Posterior to the MANDIBULAR ANGLE PLANE (MAP)
- MAP is a vertical line drawn at the angle of the mandible
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What are the regions of potential injury in neck trauma, their associated signs and symptoms, and methods of investigation?
A. VASCULAR INJURY
1. Signs and Symptoms:
- Shock
- Hematoma
- Hemorrhage
- Pulse deficit
- Neurologic deficit
- Bruit or thrill in neck
- Tests:
- Angiogram
- CT angiogram
- Doppler ultrasound
- Neck exploration
B. LARYNGOTRACHEAL INJURY
1. Signs and Symptoms:
- Subcutaneous emphysema
- Airway obstruction
- Sucking wound
- Hemoptysis
- Dyspnea
- Stridor
- Hoarseness or dysphonia
- Tests:
- Laryngotracheoscopy
- Neck exploration
- CT scan
C. PHARYNX/ESOPHAGUS INJURY
1. Signs and symptoms:
- Subcutaneous emphysema
- Hematemesis
- Dysphagia or odynophagia
- Tests:
- Contrast esophagogram
- Esophagoscopy
- Neck exploration
Describe the classes of hemorrhagic shock
Average adult blood volume = 4500-5700mL (about 5L)
- CLASS I: Up to 15% blood loss
- Approx 750mL
- Hemodynamically normal (No tachycardia, normal BP, RR)
- Normal urine output > 30ml/hr
- Mental slightly slightly anxious but normal
- Skin and cap refill: normal < 2 s - CLASS II: 15-30% blood loss
- 750-1500mL
- HR elevated (100-120)
- No hypotension - Normal sBP, decreased pulse pressure, slightly elevated RR (20-30)
- Urine output slightly lower 20-30ml/h
- Mildly anxious
- Skin and cap refill: > 2s, clammy skin - CLASS III: 30-40% blood loss
- 1500-2000mL
- Tachycardic 120-140
- HYPOTENSION - sBP decreased, pulse pressure decreased
- RR increased 30-40
- Urine output decreased 5-15mL/h
- Anxious and confused
- Skin and cap refill: > 3s, cool pale skin - CLASS IV: >40% blood loss
- More than 2000mL blood loss
- Very tachycardic (>140), hypotensive, tachypneic >35
- Negligible urine output
- Confused, lethargic
- Skin and cap refill: >3s, cold mottled skin
What are 7 indicators of major vascular injury following penetrating neck injury on chest x-ray (CXR)?
- Widened mediastinum
- Obscured aortic knob
- Deviated trachea
- Apical cap (blood at lung apex)
- NG tube deviation
- Hemothorax
- Hemopericardium
- Pleural effusion
- Pneumothorax/mediastinum
“WEAPON”
W - Widened mediastinum
E - Effusion (pleural effusion, hemopericardium, hemothorax)
A - Apical cap (blood at lung apex)
P - Pneumothorax/mediastinum
O - Obscured aortic knob
N - NG or trachea deviated
Describe the management of a Zone I injury
Zone I Injury = clavicle to cricoid
- Immediate OR if hard signs/unstable
- If no hard signs, EVERYONE GETS:
- Vascular evaluation (CT angiogram)
- Esophageal evaluation - If above investigations all negative, then observation
- If investigations above positive, then vascular OR neck exploration (Especially for vascular)
Options for esophageal evaluation:
1. Esophagoscopy
2. Barium or gastrograffin swallow
3. CT Neck
Barium vs. Gastrograffin:
- Barium: Thicker, thus more sensitive for esophageal injury, but can lead to infection if leaks into neck
- Gastrograffin: Thinner, thus less sensitive, but less likely to lead to infection with a leak
Surgical exposure options:
1. Left - Anterior thoracotomy
2. Right - Median sternotomy
Describe the management of a Zone II injury
Zone II injury = Cricoid to mandible
- Immediate OR if hard signs or unstable
- If no hard signs:
- If stable with symptoms (e.g. hematoma, subcutaneous emphysema) = selective neck exploration
- If stable with NO symptoms = directed exam (ie. vascular evaluation ± laryngoscopy ± endoscopy ± esophagoscopy depending on projectile path and examination
- If directed exam positive = neck exploration
- If directed exam negative = observation
Historically mandatory neck exploration in Zone II injuries was the standard of care, but now with advancements in imaging, a selected approach as described above is more common
Surgical exposure option:
- Hockey stick incision along anterior border of SCM
Describe the management of a Zone III injury
Zone III Injury = Mandible to base of skull
- Immediate OR if hard signs/unstable
- If stable = CT Angiography
- If CT angio positive = Vascular intervention (intravascular or open, usually more feasible to access via intravascular approach)
- If CT angio negative = observation
Surgical Exposure options:
- Extension of Zone II (hockey stick incision) to include mandibulotomy or mandible subluxation
Describe the management approach of penetrating neck trauma with a “no-zone” approach
- Presence of hard signs = Operative exploration/repair
- If no hard signs = CT angiography
CT Angio positive: Operative exploration/repair
CT Angio negative:
- If low risk trajectory: observe
- If high risk trajectory: directed angiography or panendoscopy
- Trajectory risk is vaguely defined but relates to the surroudning structures to the tract and what is around
Main difference between this and zone-based approach is the routine use of neck exploration in Zone II injury
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What are the hard signs / Immediate surgical indications for penetrating neck trauma? 9
VASCULAR SIGNS (5)
1. Shock or hemodynamic instability
2. Pulsatile bleeding / massive bleeding
3. Expanding hematoma (or hemothorax or hemomediastinum)
4. Unilateral loss of extremity pulse
5. Audible bruit or palpable thrill
“BEEPS”: Bruit or thrill, Extremity loss of pulse, expanding hematoma, pulsatile bleeding, shock
AIRWAY SIGNS (3)
1. Airway compromise
2. Extensive subcutaneous air / wound bubbling
3. Stridor/hoarseness
“ASS”: Airway compromise, subcut air, stridor
NEUROLOGIC SIGNS (1)
1. Lateralizing neurologic deficits (stroke signs)
What is the proportion of vascular injuries in neck trauma? What is the management approach to vascular injuries?
INJURIES:
- Internal jugular vein - 9%
- Internal carotid or common carotid - 7%
APPROACH:
- Ligate vs. primary repair
- Vascular patch or graft
- Involve vascular surgery
Describe the Schaefer-Fuhrman classification for laryngeal trauma
- Class I:
- Minor endolaryngeal hematoma
- No mucosal disruption or laceration
- No exposed cartilage
- No detectable fracture - Class II:
- Mild edema, hematoma
- Mild mucosal laceration and disruption but no exposed cartilage
- Undisplaced fracture - Class III: VCD
- Significant edema and mucosal disruption
- Vocal fold immobility
- Cartilage exposure
- Displaced fracture - Class IV: USA
- Undisplaced fracture, 2+ fracture lines
- Severe mucosal disruption
- Anterior commissure involvement - Class V: Complete laryngotracheal separation
Which classes of laryngeal injury require surgical management?
- Class III-V: Tracheostomy
- Class III: May be candidate for endoscopic repair
- Class IV: Open repair, endolaryngeal stent
- Class V: Open repair, tracheal reanastomosis
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What are the signs and symptoms suggestive of laryngeal trauma?
SIGNS:
1. Dysphonia
2. Dyspnea
3. Dysphagia
4. Odynophagia
5. Stridor / airway obstruction
6. Hemoptysis
7. Loss of laryngeal crepitus or thyroid cartilage eminence
SYMPTOMS:
1. Subcutaneous emphysema (crepitus)
2. Neck swelling
3. Anterior neck ecchymoses or tenderness
4. Mucosal swelling, edema, lac, hematoma
5. Cartilage exposure
6. VC or arytenoid asymmetry/dysfunction
7. Palpable deformity
Discuss the initial management of suspected laryngeal fracture
- ABCDE: Airway, breathing, circulation, disability, exposure (follow trauma protocol)
Airway: Unstable or stable?
- Impending airway obstruction: tracheostomy, then CT/DL/Esophagoscopy
- Airway stable: FNL first
FNL: Findings normal or abnormal?
- Normal: medical management, serial examination
- Abnormal: CT scan
CT findings: Airway encroached or not?
- Airway encroached: Tracheostomy, surgery
- No airway encroachment (Schaefer I/II): Medical management, serial examination
- Management on CT depends on Scaefer staging below
Surgical Management: Direct laryngoscopy, esophagoscopy, ± stenting (midline thyrotomy or anterior cricoid split), ± tracheostomy (unstable airway, Schaefer III+)
- III: ORIF, thyrotomy OR endoscopic repair
- IV: ORIF, thyrotomy, repair with endolaryngeal stent
- V: Debridement and primary anastomosis
Discuss the measures for conservative management of laryngeal trauma. 11
- Admit for observation (minimum 24 hours)
- Humidificatiion
- PPI, reflux management
- Serial endoscopic examinations
- Steroids
- Heliox at bedside
- Voice rest
- Racemic epinephrine PRN
- Antibiotics, especially if mucosal tear
- Head of bed elevation
- Possible NG if significant mucosal damage
Same as post-operative care for repaired laryngeal trauma
What are the criteria for medical management of traumatic laryngeal injuries? 6
Schaefer I/II, not III -V
- Edema
- Small hematoma
- Non-displaced single stable fracture
- Lacerations with no cartilage exposure
- Normal vocal fold movement
- No injury to anterior commissure
What are the indications for open repair of traumatic laryngeal injuries?
Schaefer III-V
Plus airway compromise, bleeding, and subcutaneous emphysema/air escaping through wound
- Mucosal lacerations that are large or involve the anterior commissure/free edge of the vocal fold
- Exposed cartilage
- Multiple or displaced fracture of cricoid and/or thyroid
- Vocal fold immobility of disruption of the cricoarytenoid joint
- Airway compromise requiring intubation/tracheotomy
- Active bleeding or hemoptysis
- Concordant injury to neck requiring surgical exploration
- Air escaping through the neck wound
What are the indications for stenting in laryngeal trauma? 5 how long to stent?
- Schaefer IV
- Unstable fracture
- 2+ fracture lines or multiple displaced laryngeal fractures
- Severe mucosal disruption / endolaryngeal lacerations
- Anterior commissural involvement
- Architecture or larynx not maintained by open fracture fixation (loss of cartilaginous framework)
Stent left in place for 2 weeks and then removed in OR as an endoscopic procedure
