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2025 Part Twos > Trauma - neck trauma > Flashcards

Trauma - neck trauma Flashcards

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1
Q

What defines a significant injury in neck trauma?

A

Defined by platysma breach

A breach indicates potential deeper injury and necessitates further evaluation.

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2
Q

What should be assumed in cases of neck injury until proven otherwise?

A

Assume significant injury until proven otherwise

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3
Q

What is a critical guideline when examining neck injuries?

A

Never probe deep to platysma!

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4
Q

What percentage of neck injuries involve multiple structures?

A

50%

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5
Q

Can wounds in the neck cross anatomical zones?

A

Yes, wounds can cross zones (ie enter in one zone and cause injury in another)

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6
Q

What type of wounds have a higher rate of injury in the neck?

A

Gunshot wounds

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7
Q

What is the anatomical definition of Zone I of the neck?

A

Sternal notch to lower border of cricoid cartilage

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8
Q

What are the contents of Zone I?

A
  • Great vessels
  • Trachea
  • Oesophagus
  • Thoracic duct
  • Upper mediastinum
  • Lung apices
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9
Q

What is the anatomical definition of Zone II of the neck?

A

Cricoid cartilage to angle of mandible

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10
Q

What are the contents of Zone II?

A
  • Carotid and vertebral arteries
  • Jugular veins
  • Pharynx
  • Larynx
  • Oesophagus
  • Trachea
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11
Q

What is the anatomical definition of Zone III of the neck?

A

Angle of mandible to base of skull

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12
Q

What are the contents of Zone III?

A
  • Pharynx
  • Distal extracranial carotid/vertebral arteries
  • Jugular veins
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13
Q

List the hard signs strongly suggestive of neurovascular or aerodigestive injury

A

Neurovascular:

Expanding/pulsatile haematoma (most important two)

Active bleeding

Neurological deficit, cerebral ischaemia

Aerodigestive:

Airway Compromise/Air bubbling in wound/haemoptysis

Haematemesis

Shock:

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14
Q

List the soft signs suggestive of neurovascular or aerodigestive injury

A

Non-pulsatile, non-expanding haematoma

Venous ooze

Subcut emphysema

Dysphagia/dyspnoea

Chest tube air leak

Minor haematemesis

Paraesthesia

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15
Q

What is the investigation of choice for stable patients with neck trauma?

A

CT

CT angiography has largely replaced traditional angiography.

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16
Q

What does CT angiography not rule out in neck trauma assessment?

A

Injuries in vascular, airway and GIT structures

Important to consider these injuries despite CT angiography.

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17
Q

Which zone injuries require angiography?

A

All Zone I and III injuries

Angiography is particularly helpful for injuries that are difficult to access.

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18
Q

Why is angiography important for Zone I injuries?

A

Due to association of vessels with thoracic outlet to plan surgery

Zone I injuries often involve critical vascular structures.

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19
Q

What is the purpose of angiography in Zone III injuries?

A

To assess relation to base of skull

Often these injuries are managed non-surgically.

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20
Q

What imaging is part of the primary survey for neck trauma, especially for Zone I?

A

CXR

CXR is crucial for initial assessment.

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21
Q

Fill in the blank: CT angiography has largely replaced traditional _______.

A

angiography

Traditional angiography is now mostly used for arterial embolization post diagnostic CT angio.

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22
Q

What are the two approaches to neck injuries?

A

Neck zone approach and no zone approach

The neck zone approach categorizes injuries based on anatomical zones, while the no zone approach relies on soft and hard clinical signs.

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23
Q

What is a key principle of initial management of neck injury according to ACLS?

A

Place Foley and inflate balloon for tamponade

This is a method used to control bleeding in neck injuries.

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24
Q

What are the indications for surgical exploration in neck injuries with the (older) zoned approach?

A

If haemdynamically stable: zone 1 & 3, investigate first, Zone 2 traditionally mandatory exploration

This includes assessing hemodynamic stability and the specific zone of injury.

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25
Which zones require investigation first if the patient is hemodynamically stable?
Zone 1 and Zone 3 ## Footnote Zone 2 traditionally requires mandatory exploration.
26
What should be done for Zone I injuries in stable patients?
Assess with CTA +/- endoscopy +/- bronchoscopy ## Footnote This approach helps in determining the extent of injury.
27
What should be administered if clamping of vessels is required?
Heparin 5000 IU ## Footnote This is to prevent clot formation during surgical procedures.
28
How are vertebral artery injuries best managed?
Angioembolisation, otherwise may need ligation at origin ## Footnote If not possible, ligation at the origin may be necessary.
29
What is a challenge in managing Zone III injuries?
Difficult to access surgically ## Footnote Techniques like disarticulation of the mandible may be used.
30
What can be used temporarily or permanently to manage bleeding in Zone III?
Fogarty catheter ## Footnote This device can help control bleeding in difficult-to-access areas.
31
What is the traditional approach to Zone II injuries?
Operative exploration if deep to platysma ## Footnote This involves specific surgical techniques to access deeper structures.
32
What is the incision approach for Zone II injuries?
Incision along anterior edge of SCM ## Footnote This helps mobilize structures lateral to the carotid sheath.
33
What is the current trend regarding selective neck exploration?
More common now, with surgery only in patients with hard signs ## Footnote This reduces unnecessary negative explorations.
34
What has reduced the rate of missed injuries in neck trauma?
Advent of CT angio ## Footnote This imaging technique enhances the detection of vascular and structural injuries.
35
Why are gunshot injuries treated with mandatory exploration?
Higher rate of injury to major structures ## Footnote This is due to the potential for significant vascular and organ damage.
36
What is the basis for the 'No' zone approach in selective neck exploration?
Presence or absence of hard signs or soft signs ## Footnote This approach focuses on clinical findings rather than the anatomical zone of injury.
37
What must be done if a patient with penetrating neck trauma is hemodynamically unstable?
Must be explored ## Footnote This is crucial unless another source of shock is identified.
38
What is the management of patients with hard signs in the context of neck injuries?
Indications for surgical exploration ## Footnote These may include active bleeding, expanding hematoma, or neurological deficits.
39
What is the management of a patient with soft signs in the context of neck injuries?
Further investigation and observation ## Footnote These may include minor bleeding or neurological symptoms that are not definitive.
40
What incision do you use to explore zone one neck injuries?
In unstable patient, midline sternotomy with supraclavicular extension can give good exposure
41
What incision do you use for zone II neck injuries
Incision along anterior edge of SCM, mobilise lateral to carotid sheath and ensure oesophagus is explored (highest rate of missed injury)
42
Haemodynamic instability with pentrating neck trauma must be: ___________
explored ( if another  source of shock is not found) 
43
44
What type of trauma is most at risk for laryngotracheal injuries?
Blunt trauma e.g. punch to throat
45
What percentage of laryngotracheal injuries are confined to the neck?
85%
46
What are common signs of laryngotracheal injuries?
* Direct injury * Pain/tenderness * Hoarseness/soft voice * Subcutaneous emphysema * Air bubbling * Dyspnoea * Stridor * Haemoptysis
47
What investigations are recommended for laryngotracheal injuries?
* Laryngoscopy * Bronchoscopy * Oesophagoscopy
48
What should be considered if a significant fracture of the larynx is suspected?
Tracheostomy
49
What is usually all that is needed for simple repair of laryngotracheal injuries?
Repair in 1 layer with absorbable suture
50
Why can oesophageal injuries often be missed?
Often missed at neck exploration
51
What is a key consideration in closing oesophageal injuries?
Mucosal layer is key
52
How should drainage be handled in oesophageal injuries?
Drain widely
53
What may be required for extensive oesophageal injuries?
Oesophagostomy for diversion/feeding
54
What percentage of penetrating neck injuries involve carotid injury?
6%
55
What dictates intraoperative decisions for carotid injury management?
Pre-operative neurology
56
What is the recommended management if there is no pre-operative neurological deficit in carotid injury?
Repair the vessel (unless complete obstruction)
57
What is the management approach for carotid injury if there is a pre-operative deficit?
Controversial; repair in patients with mild-moderate injury with retrograde flow, ligation in patients with neurological deficits >48h old and no evidence of retrograde flow
58
Describe your approach to neck exploration
Operative – Neck exploration Prep patient chest to base of skull Incision along anterior border of SCM Divide platysma and retract laterally Divide common facial vein to allow mobilisation of internal jugular Lateral retraction of jugular and carotid allows identification of trachea and oesophagus Medial retraction allows access to prevertebral tissues
59
After neck exploration with an incision along the anterior border of SCM, what additional exposure may be required? When would you use these manouvres?
Additional Exposure Median Sternotomy or Thorochotomy Zone I injuries are concerning for great vessel injury. To gain proximal control will require entry to chest. Median = best exposure. Left or right thorochotom = quicker, may help with other injuries Clavicle resection Considered for left subclavian injuries. Require resection of part of clavical, sounds like a good idea but very fiddley and difficult. Alternative is "trap-door" incision = neck incision + median sternotomy + left thoroctomy. Maximalist exposure. Très morbid!!
60
# What is this incision:
Trapdoor incision for left subclavian injuries
61
What are the Denver guidlines used for?
Blunt Cerebrovascular Trauma (BCVI)
62
What guidelines are used in Blunt Cerebrovascular Trauma (BCVI)
Denver Guidelines
63
What are the denver criteria used for?
The Denver criteria are a set of screening criteria used to determine when CT angiography of the neck is indicated to detect blunt cerebrovascular injury (BCVI) in patients presenting after trauma
64
What are grades 1-5 of the Denver grading system for managment of blunt cerebrovascular injury?
Grade I: Minimal irregularity of the vessel wall or dissection with less than 25% stenosis. Grade II: Intimal irregularity, dissection, or intramural hematoma with 25% or greater stenosis. Grade III: pseudoaneurysms. Grade IV: Complete occlusion of the vertebral artery. Grade V: Vessel transection
65
What are the clinical features concerning for BCVI?
Hard or soft signs of neurovascular injury, arterial haemorrhage, expanding haematoma
66
What mechanisms are associated with a high risk of BCVI?
Neck injury, neck soft tissue injury, hanging, direct blow to neck, high-energy mechanism
67
What types of injuries are associated with BCVI?
Fascial injuries (LeFort 2 & 3), C-spine fractures, base of skull fractures, severe TBI
68
Fill in the blank: The clinical features concerning for BCVI include _______.
hard or soft signs of neurovascular injury, arterial haemorrhage, expanding haematoma
69
True or False: A direct blow to the neck is a mechanism that carries a high risk of BCVI.
True
70
List the types of fascial injuries associated with BCVI.
* LeFort 2 * LeFort 3
71
What is the management of suspected BCVI?
Get CTA Discuss with Vascular Treatment based on Grade Grade 1-2 --> anti-platete or DOAC Grade 3-5 --> surgery or Endovascular
72
List four types of injury associated with BCVI
1. Le fort Ii or III fractures 2. Cervical spine fractures 3. Basilar skull fractures with or iwthout carotid canal involvement 4.Diffuse axonal injury
73
List six clinical symptoms and signs of BCVI (blunt cerebrovascular injury)
Arterial haemorrhage Cervical bruit Expanding cervical haematoma Focal neurological deficit Neurological findings unexplained by intracranial findings Ischaemic stroke on secondary CT scan
74
List five clinical risk factors that mandate radiological screening for BCVI
1. High energy mechanism 2. Horner's syndrome 3. Neck soft tissue injury 4. Near hanging 5. Direct blow to the neck

2025 Part Twos (85 decks)

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