John S.Oh
Trauma Surgeon, 749th Forward Surgical Team, Afghanistan 2005–2006
Trauma Surgeon, 102nd Forward Surgical Team, Baghdad, Iraq 2007–2008
Trauma Director, 10th Combat Support Hospital, Camp Bastion, Afghanistan 2011–2012
Trauma Director, 28th Combat Support Hospital, Baghdad, Iraq 2016
“The surgeon must have the heart of a lion, the eyes of a hawk, and the hands of a woman.”John Halle, 1529–1568
BLUF Box (Bottom Line Up Front)
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Secure the airway early, major neck injuries result in rapid compromise.
- 2.
Mandatory neck exploration should be your default approach in the combat and low resource settings.
- 3.
The wounded neck is unforgiving and full of potential areas prone to iatrogenic injury. Start by identifying key structures away from the injury and then work your way in.
- 4.
You can control carotid hemorrhage with one finger – don’t panic.
- 5.
Repair carotid injuries, if at all possible, or place a shunt and come back later. Ligate only as a last option.
- 6.
Reinforce an esophageal repair with buttressed tissue to separate suture lines; a failed esophageal repair will take others down with it. A missed esophageal injury = mediastinitis and death; therefore always drain the neck, even after a “negative” exploration.
- 7.
Large volume bleeding from the wound after a “negative” neck exploration is a vertebral artery injury.
- 8.
Median sternotomy should be your next move for large volume hemorrhage from the proximal carotid or subclavian (zone 1) area. Have both the neck and chest prepped and draped.
Why Is the Neck an Important Area to Understand the Anatomy and Injury Patterns?
Major vascular and aerodigestive structures pass through the neck with little or no protection from overlying bone, muscle, or soft tissue. This means an injury to the neck can result in loss of the airway from a tracheal injury, exsanguination from injury to a major blood vessel, or sepsis from a major pharyngeal or esophageal injury. It is also an area that most general surgeons infrequently operate on, so thorough preparation is the only way to make up for the lack of familiarity in an emergent case. In addition to reviewing textbooks and journal articles, trauma exposure courses using cadavers is an excellent way to stay prepared.
Mechanisms and Types of Injuries to the Neck
In order to prioritize management decisions, it is helpful to elucidate the mechanism of injury to the neck. Mechanisms of injury include blunt versus penetrating, stab wounds versus missile injury, and low versus high-velocity missile injury. Stab wounds and low velocity missile injuries can cause little damage to surrounding structures in the neck in comparison to high-velocity missile injuries. Shotgun injuries and blast injuries may cause multiple penetrating injuries to the neck, and identifying multiple trajectories and possible injuries require thorough work up. Combat wounding mechanisms tend to include high-velocity missiles as well as multiple fragments from blast injuries.
What Are the Life-Threatening Neck Injuries?
Immediately life-threatening injuries to the neck include injuries to major vascular structures such as the internal jugular vein or carotid artery and injury to the trachea. The main priority with any of these injuries, whether it is a vascular injury or a direct tracheal injury, is to secure the airway and control hemorrhage. A missed esophageal injury can also be a cause of late morbidity and mortality from infection, sepsis, and possibly mediastinitis as infection may spread along fascial planes from the neck into the mediastinum.
What Are the Injuries that Are Easy to Miss But Can Lead to Late Morbidity or Death?
In the civilian trauma literature, a selective operative management algorithm is useful in decreasing negative neck explorations but only if you have high-quality CT angiograms or interventional radiologists available to confirm that there are no major vascular, airway, or esophageal injuries present. Clinical signs, while also useful, can be unreliable for ruling out major injuries that require a neck exploration. In a deployed setting, you will often not have the luxury of a CT scan or angiography. You also may not even have the time or resources to carefully observe the patient and do serial exams to rule out an injury – particularly on a patient who needs to go into the evacuation chain back to the United States. That means you must have a low threshold to explore the neck.
A negative neck exploration has a low morbidity rate, and mortality from a negative exploration is virtually unheard of. There are several injuries to consider that are easy to miss but have devastating potential.
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Occult vascular injuries to the carotid such as a dissection or small pseudoaneurysm may be asymptomatic initially but can progress to complete thrombosis or rupture.
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Small penetrating esophageal injuries. Due to the lack of a serosal layer, the longitudinal muscularis may hide small mucosal perforations. Thus, you should always drain the neck with closed suction drains, even after a “negative” exploration.
- 3.
Penetrating oropharyngeal injuries – remember to look in the mouth and posterior pharynx for all penetrating neck wounds.
How Should I Evaluate a Patient with a Neck Wound?
The approach to a patient with a penetrating neck wound is the same as with all other traumas. The priority is to establish a definitive airway in the unstable patient, then proceed with the remainder of the A-B-C’s. In evaluating the trajectory of the injury to the neck, it is helpful to divide the neck into three anatomic zones. Zone I lies between the clavicles and the cricoid cartilage, zone II lies between the cricoid cartilage and the angle of the mandible, and zone III lies between the angle of the mandible and the base of the skull (Fig. 23.1). Remember that these refer to anterior and lateral neck wounds and not wounds that are confined to the posterior neck or superficial wounds that have not penetrated the platysma muscle.
Fig. 23.1
Zones of the neck (Reprinted from Oral and Maxillofacial Surgery Clinics of North America, 20(3), Shahrokh C. Bagheri, H. Ali Khan, R. Bryan Bell, Penetrating Neck Injuries, 393–414, Copyright 2008, with permission from Elsevier)
One of the first problems examining the neck is that someone has often placed a cervical collar, and no one wants to remove it for fear of a spinal column injury . The first maneuver you should perform is removing the collar – it is an obstruction to completing a thorough physical exam, which is of paramount importance. The likelihood of causing further neurologic injury by removing the collar is low as the degree of neurologic injury in penetrating trauma is mostly related to the initial injury.
If necessary, the collar can be replaced after your evaluation. A thorough evaluation of the neck should include observation for hematomas, pulsatile masses, arterial bruits, bleeding or air from wounds, and tracheal deviation. Feel for crepitus, carotid pulses, and bony injuries. Auscultate for bruits and breath sounds, and assess the voice for hoarseness or stridor. Examine the cranial nerves and don’t forget a good intraoral examination. Observe for any obvious hematemesis or hemoptysis. You can also have the patient spit on a gauze pad to look for any blood in the saliva suggestive of hemoptysis.
The majority of wounds to the neck lie within zone II, where the aerodigestive tract , carotid artery, vertebral artery , internal jugular vein , and cervical spine are at risk (Fig. 23.2). In addition to these structures, injuries to zone I include structures in the thoracic inlet, such as the aortic arch, proximal carotid, and subclavian vessels. Injuries to zone III include the cranial vault and pharynx. In an unstable patient with penetrating trauma to the neck, you should proceed directly to the operating room. The presence of “hard signs” of injury such as obvious uncontrolled hemorrhage, expanding or pulsatile hematomas, “sucking” neck wounds, unexplained hypotension, or lateralizing neurologic signs should also prompt immediate surgical exploration. If you have a hole in the neck and hard signs of a vascular injury, you do not need a CT scan to confirm the injury or to tell you where it is. You need to be in the OR for a neck exploration and prepared to do a sternotomy or clavicular extension.
Fig. 23.2
Critical anatomy of the neck for trauma neck exploration : (1) facial nerve; (2) internal carotid artery; (3) external carotid artery ; (4) spinal accessory nerve; (5) internal jugular vein ; (6) vagus nerve; (7) cervical plexus; (8) mandible; (9) facial artery; (10) lingual nerve; (11) mylohyoid muscle; (12) hypoglossal nerve; (13) lingual artery; (14) superior thyroid artery; (15) common carotid artery (Reprinted from Oral and Maxillofacial Surgery Clinics of North America, 20(3), Shahrokh C. Bagheri, H. Ali Khan, R. Bryan Bell, Penetrating Neck Injuries, 393–414, Copyright 2008, with permission from Elsevier)
In the civilian literature, zone I and III injuries are often first evaluated by a combination of CT scan, bronchoscopy, esophagoscopy, esophagogram, and angiography. Zone II injuries are typically explored in the operating room if they present with classic “hard signs.” Otherwise, they are managed nonoperatively with imaging and close serial examination. In austere settings where thorough, nonoperative evaluation is not possible, penetrating injuries to any of these zones require surgical exploration. In these cases, you will do some negative or nontherapeutic explorations, but you will find significant injuries much more commonly than is reported with civilian trauma mechanisms. However, due to the low morbidity and mortality of a negative exploration, this is acceptable. It is far more devastating to have a missed injury or delayed therapy. All wounds penetrating the platysma muscle, as well as all high-velocity and transcervical neck wounds, should prompt exploration.
The blast victim who has multiple tiny fragment wounds involving the neck without hard signs of neck injury can pose a diagnostic dilemma. These fragments could have caused significant injuries to any neck structure, or they may just be superficial injuries that have not penetrated the platysma. If the patient has a normal neck examination as outlined above and is hemodynamically stable, then you should obtain a CT arteriogram of the neck if available. This should identify the vast majority of major neck injuries and also identify the location of any retained fragments. If the exam and the CT scan are normal, then the patient can be safely observed. If there is any concern for an esophageal injury, then swallow study and/or endoscopy must be added to your evaluation. Watch this patient for at least 24 h to ensure stability and no delayed manifestation of an occult injury. If close observation for up to 48 h and these diagnostic adjuncts are not available, then neck exploration is recommended.
Techniques of Exposure, Exploration, and Repair of the Common Injuries
Vascular Injuries: Common, Internal, and External Carotid Arteries, Jugular Vein
The general approach to a penetrating neck injury is to prep and drape from the base of the skull to the knees. Shave the groin and thighs for possible saphenous vein harvest. In addition, take the time to position your patient properly. This includes a shoulder roll underneath the shoulder blades to help extend the neck. If you have unilateral injury, turn the head slightly away from you, and use a head support. Proper positioning will greatly enhance the operative exposure of the neck. If there is concern for cervical spine injury, this may not be possible, and the neck should be maintained in the neutral position.
There are multiple incisions and extensions that can be used in the neck (Fig. 23.3). For trauma exploration, the basic incision for penetrating neck trauma is along the anterior border of the sternocleidomastoid muscle (SCM) , just as you would for a carotid endarterectomy. The incision should extend from the mastoid process to the sternal notch. This incision will allow access to the major vascular and aerodigestive structures of the neck. Exposure of the esophagus is best gained via the left neck but can be obtained from either side. You should always be prepared to extend your incision inferiorly into a median sternotomy for proximal vascular control or to “hockey stick ” the inferior end of the neck incision transversely across the clavicle to expose the subclavian vessels. Do not hesitate to resect a portion of the clavicle or disarticulate it from the manubrium to gain full exposure of the subclavian vessels. Finally, for bilateral neck explorations, you can either make mirror image standard incisions or make a collar incision with bilateral superior extensions along the SCM .
