Penetrating Neck Injury

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จาก Cumming's Otolaryngology - Head & Neck Surgery, 5th Edition (2010)

Sign & Symptom

  • Airway: Respiratory distress, Stridor, Hemoptysis, Hoarseness, Tracheal deviation, Subcutaneous emphysema, Sucking wound
  • Vascular: Hematoma, persistent bleeding, neurodeficit, absent pulse, shock, bruit, thrill
  • Nervous: Hemiplegia, quadriplegia, coma, CN deficit, hoarseness
  • Esophagus/hypopharynx: subcutaneous emphysema, dysphagia, odynophagia, hematemesis, hemoptysis
Handgun
  • Impact 50 m/s เข้า skin, 65 m/s fracture bone
  • Civilian - Low-muzzle velocity (90 m/s)
  • มักเบียด vascular structures มากกว่า
  • High velocity bullet: > 610 m/s
  • Handgun/pistol (.22, .45) : 210-600 m/s
  • Magnum .44 : greater velocity – injury comparable with rifle
  • กระสุนที่เบี่ยงวิถี/เด้ง จะสร้างความเสียหายมากกว่า
Rifle
  • Mostly 760 m/s
  • Created cavity up to 30 times the size of bullet
  • High energy missiles not easily deflected, cause significant destruction along path (energy absorbed)
  • Mortality is significant, usually not survive to study
Shotgun
  • Pellets scatter as they travel
  • At close range: act like single missile similar to high-velocity bullet of rifle (blast)
  • At further distance: act like multiple bullet (depends on gauge, shot, powder load and choke of gun) – may be hidden in multiple locations
  • Low-velocity (300 m/s)


Table 115-2 Classification of Birdshot Shotgun Wounds

Range

Type Standard Barrel Sawed-off Shotgun Injury Mortality (%)
0 Long >12 m >4 m Superficial—pellets in skin only 0
I Long >12 m >4 m Penetrates only subcutaneous tissue 0-5
II Close 5-12 m 2-4 m Penetrates beyond deep fascia 15-20
III Point blank <5 m 0-2 m Extensive tissue damage 85-90

Sign of immediate life-threatening injury: Immediate exploration!
  • Massive bleeding
  • Expanding hematoma
  • Nonexpanding hematoma + hemodynamic instability
  • Hemomediastinum
  • Hemothorax
  • Hypovolemic shock
Stable patient: exploration or close monitor

Classification of neck zone
  • Zone I: below cricoid: vital vascular structures close to thorax. Mortality 12%. Angiography suggested before exploration. Not recommend mandatory exploration
  • Zone III: above angle of mandible: difficult to explore. Abnormal neuro exam suggest need for angiography (CN close to vessels – hypoglossal-carotid, Horner’s syndrome due to injury of sympathethic chain around carotid)
  • Zone I & Zone III with stable, without airway obstruction/heavy bleeding/expanding hematoma: angiography +- barium swallow (Zone III beware hematoma in parapharyngeal/retropharyngeal space)
  • Zone II: controversy, leading cause of death: hemorrhage
Initial management
  • Airway management
    • Intubation
    • Cricothyroidotomy
    • Tracheostomy (safer when OC/pharynx/larynx are traumatized)
  • Blood perfusion management
    • IV large bore + fluids
  • Clarification/classification of severity of wound
    • No probing (clot dislodgement and uncontrolled bleeding may occur)
    • Film neck AP – lateral
    • Film CXR: manage pneumo/hemothorax

Management of vascular penetration
  • Zone I: thoracic approach (low cervical not sufficient) – mediastinotomy / lateral thoracotomy
  • Zone III: may require mandibulotomy
  • All vein in neck can be safely ligated to control hemorrhage (if 2 IJV interrupted – attempt to repair one)
  • Branches of external carotid artery may ligated because collateral circulation is good

One response to “Penetrating Neck Injury

  1. DoRaePEET

    เลือกไม่ถูกเลยว่าจะใช้อย่างไหนดี ^^"

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