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Neck Trauma PowerPoint Presentation

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Description : PowerPoint presentation on Neck Trauma, download now ppt of Neck Trauma

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Published on : Jan 08, 2015
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Slide 1 -

Neck Trauma

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Penetrating trauma Blunt trauma Near - Hanging & Strangulation

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Penetrating Trauma Symptoms of injuries to structures such as the esophagus can be subtle or delayed in presentation

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Pathophysiology Mechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous

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Organ System Classification Vascular ( most common ) Pharyngoesophageal Laryngotracheal Others ( cranial nerve, thoracic duct, brachial plexus, spinal cord….

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Vascular Three pathophysiologic mechanisms External hemorrhage Extending soft tissue hematoma, distort or obstruct the airway Disruption of cerebral perfusion ( CVA )

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Pharyngoesophageal Rarely causes any immediate consequence Delayed diagnosis can lead to serious soft tissue infection, mediastinitis and sepsis

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Laryngotracheal Small puncture wound Airflow away from respiratory tree Obstruction of airway

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Wound Location Classification Anterior (Sternocleidomastoid muscle ) Posterior Anterior Zone 1 ( below cricoid cartilage ) Zone 2 ( between the cricoid cartilage and mandible angle ) Zone 3 ( above mandible angle )

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Management of Penetrating Trauma Stabilization Critically injured patient Rapidly assessing vital functions and the area of injury Performing stabilizing interventions Initiating a diagnostic workup Definitive care No immediate life threat Violates the platysma ( explore at OR ) * If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order

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Airway The risk of spinal cord injury is minimal Cervical cord injury in a gunshot wound victim when intubation has never been reported Preintubation radiography is significant

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Airway General Most difficult management dilemma: awake patient with impending airway obstruction Preoxygenation is important # Comatous patients & patients in respiratory distress require immediate intubation # It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED )

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Airway Method Oral & nasal intubation with or without endoscopic guidance or muscle relaxants Percutaneous transtracheal ventilation ( PTV ) Surgical airway

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Airway Method PVT Airway remains unprotected & uncomfortable in conscious patient Temporary intervention Complication and contraindication 1. Significant airway obstruction & penetrated airway 2. Subcutaneous emphysema, pneumothorax

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Airway Method Surgical Airway Last resort ( direct injury to the airway is exception ) cricothyrotomy Tracheostomy or even intubation via the wound

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Hemorrhage External hemorrhage Direct pressure Blindly clamping bleeding vessels is avoided Quick transfer to the operating room Inter Hemorrhage Airway compromised Zone 1 injury result in hemothorax ( thoracostomy )

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Definitive Management of Penetrating Trauma Unstable patient Immediate transfer to the OR Stable patient General Mandatory exploration Selective Approach

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Definitive Management Stable Patient General Lateral neck film CXR ( especially in zone 1 injuries ) NG tube should not be inserted Prophylactic antibiotics Mandatory exploration Selective Approach A selective method reserves operative intervention for patients with clinical signs of significant injury

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Clinical Findings:Require Surgical Intervention Using a Selective Approach Expanding or pulsatile hematoma Presence of a bruit Horner syndrome Subcutaneous emphysema Air bubbling through wound Hemoptysis or blood - tinged saliva Shock or active bleeding Absent peripheral pulses Respiratory distress Others are observed & undergo various diagnostic studies

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Other Diagnostic Studies Bronchoscopy Esophagography Esophagoscopy Angiography # Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies

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Disposition of Penetrating Neck Trauma No indication for surgery ==> admission for at least 24 hrs

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Blunt Trauma Rare, compared with penetrating trauma Motor vehicle crash or an assault Off - road vehicles

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Classification of injuries Larygotracheal Pharyngoesophageal Vascular : delayed dissection or thrombosis ( CVA )

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Four recognized mechanisms by which thrombosis can occur A direct blow to the neck A blow to the head that causes hyperextension and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels Blunt intraoral trauma Basilar skull fracture

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Spinal column and spinal cord injuries are more prevalent in blunt trauma

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Clinical Feature Physical findings may be lacking , it is important to elicit symptoms 1 .Dysphagia, odynophagia 2.Voice quality 3.Aphonia, muffled voice ( serious injury )

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Management of Blunt Neck Trauma Whether the patient has laryngotracheal injury?

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Definitive Management General C - spine X-ray CXR Additional Studies Laryngotracheal Vascular Pharyngoesophageal

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Additional Studies Laryngotracheal Plain radiographs CT endoscopy ( fiberoptic bronchoscopy ) ( Consult chest surgeon or ENT ? ) Vascular Angiography Color Flow Doppler ultrasound Pharyngoesophageal Threshold for performing diagnostic studies should be low Esophagram & esophagoscope ( Consult chest surgeon )

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Disposition of Blunt Neck Trauma Laryngeal injuries do not require immediate repair Tracheal injuries should receive prompt surgical attention

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Near - Hanging & Strangulation Classification of Strangulation Hanging ( most common ) Ligature strangulation Manual strangulation Postural strangulation

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Clinical Features Superficial & Deep Neck Respiratory (delayed mortality) Bronchopneumonia Aspiration pneumonitis Delayed airway obstruction ARDS Neuro psychiatric

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Management Spinal cord injury is very rare Phenytoin: useful in preventing ischemic cerebral damage Naloxone Ca2+ channel blocker

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Summary Structured approach to these patients, regardless of mechanism is essential to optimize outcome & avoid catastrophe

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