Penetrating neck injury

Hard and soft signs

80% can be managed non-operatively. 10% have hard signs and need immediate operation.

Indications for immediate surgery (hard signs):

• Air bubbling through wound (airway compromise)
  • (If air leak through wound, one attempt at intubation through mouth, then enlarge the wound and get an ETT along the path of the bubbles into the trachea; if this is unsuccessful, do a rapid tracheostomy)
• Unstable patient with severely bleeding neck wound, an expanding or a pulsatile haematoma
• Neurologic deficit consistent with cerebral ischaemia
• Absent or diminished radial pulse
• Massive haematemesis or haemoptysis
• Respiratory distress

Investigation (soft signs):

• CT angio for possible vascular injuries (moderate to large haematoma, pulsatile but stable haematoma, pulse deficit, bruit, Foley catheter balloon tamponade, any mediastinal widening on CXR, retained knife blade)
• Laryngoscopy and bronchoscopy for laryngeal or tracheobronchial injuries (dysphonia, hoarseness, tension PTX, severe surgical emphysema, persistent air leak from chest drain)
• Contrast oesophagography and endoscopy for pharyngeal or oesophageal injury (odynophagia, dysphagia, haemoptysis, haematemesis, subcutaneous emphysema, blood in NGT, leakage of saliva or GIT content from wound, prevertebral air on lateral neck radiography or pneumomediastinum
• CT angio for trans-midline gunshot wounds

Zone-based approach:

• Previously, zone-based dogma mandated exploration for zone II injuries, while zone I and III were observed if stable, since those zones were harder to access
• The 'no-zone' approach is now favoured
• Zone 1 - sternal notch to cricoid cartilage - vessels, trachea, oesophagus.
  • Unstable - usually requires a median sternotomy in addition to anterior SCM incision
  • Stable - observe if possible, or endovascular management
• Zone 2 - cricoid cartilage to angle of mandible - major neck vessels, carotid bifurcation, trachea and larynx.
  • Longitudinal incision along the anterior edge of SCM, >2cm below angle of mandible
  • Exposure of CCA is described under CEA topic
  • Traditionally - exploration
• Zone 3 - angle of mandible to base of skull
  • Very difficult to assess surgically
  • Only bleeding injuries require management, and those are best treated endovascularly
  • Traditionally - observe
• Stepwise initial control of major haemorrhage:
  • Zone 1
    • Blind finger compression/Foley catheter
    • Rapidly enlarge the skin defect and use two or three fingers to compress the defect
    • Tight packing and transport to OT
  • Zone 2
    • Direct compression with finger and take to OT
  • Zone 3
    • Finger compression (often only partially successful due to deep location, but if manual compression can be maintained, get the patient to OT)
    • Fogarty  #3 or #4 catheter advanced into the wound and inflated, until haemorrhage is controlled
    • Foley balloon catheter trialled
    • Anterior SCM incision, expose ICA, insert 3/4 Fogarty inferiorly and inflated until control is achieved
    • Once temporary control is obtained, get the patient to angio for endovascular control

Specific injuries

• Isolated venous injuries will generally not require exploration, and will self-tamponade
• Anterior and external jugular veins can be ligated with impunity
• IJV can be repaired or ligated (repair with transverse venorrhaphy if possible). If contralateral IJV is uninjured, avoid complex repairs and just ligate.
• Carotid artery - primary repair when possible
  • If defect >2cm, needs graft (prefer saphenous vein)
• Vertebral artery injuries are difficult. Hard to get control. Vascular control is easiest at take-off from subclavian, but this is a hard dissection. May be easier to embolise.
• Tracheal injury - expose, debride, primary repair. Use interrupted absorbable sutures with knots on outside.