Penetrating Injuries of the Neck

Symposium on Trauma

Penetrating Injuries of the Neck Israel Penn, MD. *

In present day society, with its increasing incidence of violence, it is mandatory that surgeons be familiar with the handling of a wide variety of injuries. This applies particularly to the management of penetrating wounds of the neck, as a large number of vital structures are located in a relatively small area. Failure to recognize and deal promptly with injuries to these structures may have disastrous consequences. The present report is based on a series of 50 patients treated by the author during a 37 month period spent working at the Baragwanath Hospital in Johannesburg, South Africa. At the time this series was collected the hospital served an urban African population of about 600,000 people. Approximately 8500 cases of major trauma were treated annually, of which 2300 were for stab wounds of various parts of the body.

CLINICAL MATERIAL Of the 50 patients, 42 were male and 8 female. The ages ranged from 16 to 50, with an average of 27 years. All the injuries were stab wounds, usually with knives, but screwdrivers, sharpened bicycle spokes, and bottle fragments were also used. There were 57 stab wounds of the neck. Thirty-six involved the left side, 15 the right side, and 6 were in the midline. In 51 instances the entrance wounds were situated anteriorly, and in 6 instances the posterior half of the neck was involved. Forty wounds involved mainly the lower half of the neck, while 17 were confined mainly to the upper half. One wound resulted from an attempt at suicide and the remainder were inflicted by assailants. An added hazard was that most patients were intoxicated. All patients in this series were treated by early surgical exploration of all neck wounds. The track of each wound was followed to its depth and each structure in or near it was carefully examined. "Associate Professor of Surgery, University of Colorado School of Medicine; Chief of Surgery, Veterans Administration Hospital, Denver, Colorado Surgical Clinics of North America- Vol. 53, No, 6, December 1973

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Anatomic Distribution of the Injuries These are listed in Table 1. One major anatomic structure was involved in 11 patients, two in 14 patients, three in 2 patients, and one patient each had involvement of 4, 5, and 6 major structures respectively. Twenty patients had injuries of less important vessels and nerves or muscle injuries. Other Injuries In addition to the neck wounds 20 patients (40 per cent) had injuries to other parts of the body. These additional problems sometimes compounded the difficulty in an already formidable clinical situation. These injuries were single (7 patients) or multiple (13 patients) stab wounds involving the face, arms, hands, back, chest, or abdomen. Seven patients Table 1. Anatomic Distribution of the Injuries Vascular and lymphatic injuries ARTERIAL

12

Common carotid External carotid Vertebral Subclavian Other VENOUS

3 6 15

Internal jugular Subclavian Innominate External jugular Other

3 4 3 3 2

ARTERIOVENOUS FISTULA

Subclavian artery to internal jugular vein THORACIC DUCT

Larynx, trachea, lungs and pleura Larynx Trachea Lung parenchyma" Pneumothorax Hemothorax Hemopneumothorax

2

17 3 1 3 2 2 9

Pharynx and esophagus

4

Neurologic Brachial plexus Suprascapular nerve Phrenic nerve Hypoglossal nerve Facial nerve

8

Miscellaneous structures Parotid gland Thyroid gland Compound fracture of mastoid process

4

':Associated with pneumothorax and/or hemothorax.

2

3

2 1

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had penetrating stab wounds of the chest. If these are considered together with the cervical stab wounds, in which the apical pleura was involved, then 20 patients (40 per cent) had penetrating chest injuries. Three patients had penetrating abdominal injuries necessitating laparotomy for repair of the diaphragm and liver in one case, wounds of the stomach and liver in a second case, and wounds of the stomach, duodenum and inferior vena cava in a third patient. In addition, one patient had a compound depressed fracture of the skull which required operative treatment.

Mortality Three patients died, gIvmg a mortality of 6 per cent. All deaths resulted from major venoUs injuries. In two instances the right subclavian vein and apical pleura were involved and death from uncontrolled hemorrhage occurred before adequate exposure of the bleeding area could be obtained. The third death occurred in a patient whose neck injuries involved the apical pleura and upper lobe of the right lung, with a large hemopneumothorax, but who also had penetrating wounds of the stomach, duodenum, and inferior vena cava. Death was caused primarily by exsanguination from the vena caval injury. Complications Four complications (8 per cent) occurred in three patients. In one patient massive hemorrhage from a minute wound in the right common carotid artery, which had apparently been overlooked at the initial exploration, occurred when a drain was removed from the neck on the fifth postoperative day. The patient developed severe shock and a massive right hemothorax. Prompt reoperation with repair of the wound in the carotid artery was lifesaving. Despite drainage of the pleural cavity a clotted hemothorax developed and required subsequent decortication. The apical pleura was accidentally opened in a second patient and required insertion of a chest tube for control of the resultant pneumothorax. Mild sepsis also occurred in the neck incision. In the third patient an aneurysm developed 4 weeks after a difficult repair of a through-and-through stab wound of the subclavian artery. This was resected 6 weeks after the initial injury. OPERATIVE MANAGEMENT Based on the above experience and that of other authors/- 5 , 7, 9, 11-15 the following principles of management of penetrating wounds of the neck are recommended: 1. Maintenance of an adequate airway and the restoration of normal respiratory mechanisms. 2. Control of hemorrhage and adequate treatment of hypovolemia. 3. Early exploration with definitive surgical treatment. 4. Treatment of other injuries. Depending on their severity, these may receive priority over treatment of the neck wound.

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Respiration Upon arrival in the hospital the patient is immediately evaluated for evidence of respiratory obstruction and adequacy of ventilation and circulatory status. Respiratory obstruction may be caused by direct injury to larynx or trachea, by aspiration of blood or vomitus, by pressure of a hematoma or emphysema of the cervical tissues, or edema resulting from injuries to adjacent structures in the neck or floor of the mouth. 5 Immediate aspiration of blood and secretions from the mouth and trachea should be done, followed by insertion of an endotracheal tube or performance of a tracheostomy under local anesthesia. Subsequently, thorough tracheal toilet is often required to remove aspirated blood. Hemorrhage If active bleeding is present it should be controlled with pressure. Probing of the wound in an attempt to clamp bleeding vessels may cause further damage and blood loss and is, therefore, avoided. If shock is present a large bore needle or polyethylene catheter is inserted into a large vein; a vein in the lower extremity is used if injury to the veins draining the upper extremities is suspected. Blood volume replacement is started with lactated Ringer's solution, saline, or plasma while whole blood is typed and cross matched. If shock is severe and does not improve promptly with this type of fluid replacement, type 0, Rh negative, low titer, unmatched blood should be rapidly infused until matched blood is available. If major hemorrhage is present, resuscitation should be carried out in the operating room, not in the emergency room. Measurement of central venous pressure and urinary output are useful to monitor the response to therapy. The importance of adequate preoperative blood replacement must be stressed. If this is not done, irreversible circulatory failure may follow the induction of anesthesia, because of elimination of the compensatory mechanism of peripheral vasoconstriction. Both the surgeon and the anesthesiologist should be alert to any changes in respiratory patterns that may indicate the delayed onset of pneumothorax or hemothorax. 5 ,7 Other Early Therapeutic Measures The apical pleura and lung extend into the root of the neck and may be injured by a wound in this area, resulting in a pneumothorax, hemothorax or hemopneumothorax. When these are suspected, closed chest drainage must be instituted immediately by insertion of one or more intercostal catheters. If suspicion is high and the patient fails to respond to other proper resuscitative measures, it is not necessary to wait for radiologic confirmation of the diagnosis before instituting this therapy. Once respiratory problems and hemorrhage have been brought under control, the patients are fully examined to determine the extent of the cervical injuries, and for evidence of injuries elsewhere. When indicated, and if the patient's systemic condition is stable, ancillary investigations such as chest radiographs, angiograms, laryngoscopy, bronchoscopy, pharyngoscopy, or esophagoscopy may be undertaken. In missile wounds, radiographs of the neck may help to locate the fragmeni:(s) and to outline the track by demonstrating abnormal air or fluid collections.

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Tetanus prophylaxis is instituted. Antibiotic therapy should be given in most instances, except in cases with minimal injury caused by a clean knife wound. This treatment is particularly indicated where there has been extensive tissue destruction by high velocity missiles or spillage of alimentary secretions in wounds of the pharynx and esophagus. Often the patient has a full stomach which needs to be emptied. However, insertion of a nasogastric tube carries the risk of restarting or increasing hemorrhage as a result of coughing and gagging. Gastric emptying may have to be delayed until the trachea has been intubated under local anesthesia and general anesthesia has been instituted. In this series most of the wounds were situated in the lower half of the neck. This is typical of stab wounds, which tend to be directed downward toward the root of the neck. This is a highly dangerous area, as the great vessels are liable to be injured in a relatively inaccessible position behind the clavicle. The predominance of left-sided involvement is also a typical feature of stab wounds of the neck. 2 Exploration There is controversy as to whether all neck wounds need to be explored. Some authors l3 • 14 explore the neck if there is evidence that a major structure has been injured, but treat the remaining patients expectantly. However, the external appearance of a neck wound may be grossly misleading, and serious injury to blood vessels, esophagus, or trachea may be present. Unless the neck is explored, these injuries may not be diagnosed and may result in serious complications or death. In this series, all stab wounds of the neck were explored. Many authors feel that this is the only safe policy.I-5, 7, 9, 11, 12, 15 This is borne out by the findings of Fogelman and Stewart4 who had a 6 per cent mortality if the neck was promptly explored, compared with 35 per cent if exploration was omitted or postponed. The importance of early exploration cannot be overemphasized. Procrastination may result in delayed severe or uncontrollable hemorrhage, airway compromise, fatal or crippling brain damage, severe or lethal sepsis, fistulas of the alimentary tract or of the thoracic duct, or the late development of aneurysms or arteriovenous fistulas. In addition, if surgery is delayed, the operation is technically difficult because of diffuse infiltration of fascial planes and muscles by hematoma, compounded by the associated inflammatory reaction. At the time of operation the entire chest should be prepared and draped in cases where there is any suspicion that the chest may need to be opened to secure hemostasis. Depending upon the position of the wound, exposure may be obtained through a variety of approaches. Wide exposure is essential. Most commonly a transverse incision or an incision along the anterior border of the sternocleidomastoid muscle is used. With the latter incision, exposure can be increased by angling the incision posteriorlyalong the upper border of the clavicle and dividing the insertion of sternocleidomastoid and transecting the omohyoid. Virtually all vital structures are exposed in this way. When injury to the subclavian vessels is suspected, these may be exposed by excision of the medial half of the clavicle, through a thoracotomy incision through the fourth intercostal space, or by splitting the upper sternum and raising an osteoplastic flap

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containing the split manubrium, the medial half of the clavicle, and the anterior ends of the first and second ribs. Cleancut stab wounds of the neck do not require debridement, but high velocity missiles cause much more serious injuries. The blasting effect may cause extensive injury to many of the vital structures within the neck. a, 4,15 All devitalized tissues must be removed, including vascular, esophageal, and tracheal tissues. Wound drainage is necessary whenever extensive soft tissue damage is present and for injuries involving the airway or the pharynx and esophagus. Vascular Injuries Many vascular injuries may be easily misdiagnosed when the lesion has been effectively tamponaded by the cervical fascia. An apparently innocuous looking skin wound may hide a potentially lethal injury. Vascular injuries may be suspected because of external bleeding, a hemothorax, an established or expanding hematoma, a palpable thrill, a bruit, or absent or diminished peripheral pulses. Preoperative or intraoperative angiography may be of great value in diagnosis and treatment in selected cases, particularly those involving the internal carotid or vertebral arteries. 9 If active bleeding is present, pressure on the affected area is maintained until proXimal and distal control of the vessel can be obtained. The vessel may be repaired or it may be ligated proXimal and distal to the injured area. As collateral blood supply is excellent, any of the vessels in the neck can be ligated with impunity except for the internal and common carotid arteries and the vertebral artery in some cases.9 However, where circumstances permit, we prefer to repair injuries of major arteries. Vessels damaged by high velocity missiles require debridement. It is unnecessary to excise 1 cm. of artery on either side of the grossly damaged segment. The vessel is debrided until normal looking vessel wall is reached. 2, a End-to-end anastomosis of the mobilized vessels is often possible. If a significant segment of a major vessel is lost it can be replaced with an autogenous vein graft. Questions have been raised as to whether it is always advisable to attempt to restore circulation through an injured common or internal carotid artery.2 Intracranial hemorrhage is a well recognized complication following revascularization in the treatment of acute stroke. 16 Cerebral infarction has also been reported following restoration of carotid blood flow following occlusion of the carotid arteries as a result of nonpenetratingti and penetrating2neck injuries. A key factor in deciding upon the 'best course of action in the treatment of penetrating carotid artery injuries is the presence or absence of a neurologic deficit.2 If the patient is neurologically intact, as is usually the case, it indicates that there is an effective collateral circulation through the circle of Willis. Vascular repair is then indicated. An internal shunt is usually not necessary, but care must be taken to provide adequate blood replacement in order to ensure good perfusion pressures to the brain via collateral channels while the carotid artery is clamped. Under these circumstances previously healthy young patients can tolerate carotid, and even innominate, artery occlusion for over an hour if the patient is normotensive. 2, a In the uncommon event where impairment of neurologic function is present, the situation is simi-

if

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lar to that of patients undergoing immediate or early surgery for acute stroke. 2There is a very real danger of converting an anemic infarct of the brain into a hemorrhagic infarct by restoration of vascular continuity. Ligation of the injured artery may be the procedure of choice for many patients in this category.2 Ligation of the injured vessel may also be indicated in cases where there has been considerable damage to the vessel with a great deal of necrosis of surrounding tissues. In these cases the risks of cerebral complications secondary to ligation may be less than the risk of death from secondary infection and hemorrhage from breakdown of the arterial anastomosis. 4 The overall mortality of carotid artery injuries is 15 per cent. 2 Injuries involving the internal carotid artery between the angle of the mandible and the base of the skull are difficult to treat. Exposure is difficult and mobility of the vessel for repair is restricted owing to its passage through the carotid foramen. This may necessitate ligation of the vesseP Vertebral artery injuries are uncommon. It may be difficult to obtain distal control of the vessel as it runs through the foramina transversaria of the cervical vertebra. Occasionally it may be necessary to remove portions of the transverse processes of the cervical vertebra to obtain adequate control. Ligation of an injured vertebral artery is usually well tolerated, but in a small percentage of cases may be followed by fatal midbrain or cerebellar necrosis. 9 If a preoperative angiogram demonstrates a hypoplastic vertebral artery on the contralateral side then every effort should be made to repair the injured vertebral artery in order to avoid this complication.9 The mortality of vertebral artery injuries has exceeded 50 per cent,4 probably because of the difficulty in obtaining proximal and particularly distal control of the vessel in its intraosseous course. Penetrating injuries of the veins of the neck are associated with the risk of air embolism. Prompt pressure on open veins will prevent this complication. Established air embolism should be suspected if auscultation of the heart reveals a rumbling noise. The patient should be turned so that the left side of his body is down. Aspiration of the right atrium may be life-saving. 1 While a small clean cut wound of a major vein may be repaired, most venous injuries are best handled by ligation proximal and distal to the site of injury. Veins in the neck, including both internal jugular veins, as well as the anterior and external jugular veins, can be ligated with very little risk. 1 The paravertebral venous system is adequate to return the blood to the general circulation in the absence of all other veins of the neck. 1

Injuries to Other Structures Injuries of the thoracic duct are best treated by suture ligation of the divided proximal and distal ends. 10 End-to-end anastomosis of the divided duct is possible but the vessel is thin and fragile and there is a high incidence of breakdown of the anastomosis. 4 Ligation of the thoracic duct is compatible with normal life as there are numerous communications between the thoracic duct and the right lymph duct, as well as numerous lymphaticovenous connections. 10 In cases where routine early explora-

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tion of neck wounds is not practiced, a thoracic duct injury may present later as an external chylous fistula or as a chylothorax. Firm pressure dressings will often control the leak. In addition, in cases of chylothorax the chest will require needle aspiration or tube drainage. If copious leakage occurs intravenous replacement of fluids, electrolytes, and proteins may be necessary. In cases which fail to close with these measures, exploration of the neck may be necessary to control the leak at its source. IO Possible injury of the airway should be suspected with all wounds at or near the midline. Patients with laryngeal or tracheal injuries may present with dyspnea, cyanosis, hemoptysis, subcutaneous emphysema, dysphagia, hoarseness, or bubbling of air and blood from the wound. The diagnosis may be confirmed by laryngoscopy or bronchoscopy. Prompt provision of a clear airway is the first priority and often necessitates performance of an emergency tracheostomy under local anesthesia. A cuffed tracheostomy tube should be inserted to prevent aspiration of blood, saliva or gastric contents. The neck may then be explored under general anesthesia with repair of the wounds in the cartilage and soft tissues of the larynx or trachea. Wide drainage of the cervical wound is advisable. In high velocity missile wounds with appreciable destruction of the thyroid cartilage, temporary laryngeal stents should be used to provide internal support of the damaged larynx. 3 The stents are tethered above and below through the tracheostomy. Damaged bits of hyoid bone may be removed, but every effort should be made to preserve the cricoid ring, which is vital for a functioning airway and vocal apparatus. Every reasonable effort should be made to obtain skin coverage over injured thyroid a,nd cricoid cartilages. Patients with extensive defects of the trachea may require treatment with skin, fascial, or cartilage grafts.4 Stricture formation is a late complication of extensive laryngotracheal injury and may require repeated dilatations or reconstructive surgery. Whenever the larynx or trachea are damaged, esophageal or pharyngeal injuries must always be suspected and these structures must be carefully examined. Patients with pharyngeal and esophageal injuries may present with dysphagia or spitting up of blood. The diagnosis may be confirmed by radiographic demonstration of leakage following a Lipiodol swallow, or by preoperative or intraoperative pharyngoscopy or esophagoscopy. The wound in the pharynx or esophagus should be repaired in 2 layers with catgut sutures. If a small perforation of the pharynx is inaccessible to suture, satisfactory healing may occur with drainage alone. 4 Large defects can rarely be bridged by end-to-end anastomosis, as the esophagus is relatively immobile. If there is extensive soft tissue injury a temporary cervical esophagostomy may be necessary. Split skin grafts, fascia lata grafts, and preserved segments of aorta have been used successfully to bridge large defects.4. 15 However, persistent fistulas and strictures of the esophagus may result from extensive injury and often require secondary surgery. The neck wound should be widely drained because of the danger of mediastinitis. Postoperatively the patient should take nothing by mouth for several days and parenteral feeding may be necessary, or the patient can be fed through a nasogastric tube. Patients with extensive injuries of the pharynx or esophagus will require a gastrostomy for feeding.

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Nerves which may be injured in the neck include the spinal cord, the brachial and cervical plexuses and their branches, various cranial nerves, and the cervical sympathetic chain. There is considerable controversy about immediate as opposed to delayed repair of nerve injuries. If the patient's systemic condition is satisfactory, and the nerve is cleanly cut across, primary repair with interrupted fine silk sutures is satisfactory and was used in all nerve injuries in this series. Primary repair should not be undertaken in gunshot wounds or other massive or contaminated wounds but the severed ends of important nerves should be tagged for easier identification at a future reparative operation. Important nerves to consider for repair are the hypoglossal, spinal accessory, vagus, recurrent laryngeal, and phrenic nerves and the brachial plexus. Transection of the vagus nerve not only results in vocal cord paralysis, but abolishes the cough reflex of the homolateral bronchial tree and increases the difficulty of maintaining adequate tracheobronchial toilet postoperatively.4 Injury to the phrenic nerve may not produce paralysis of the hemidiaphragm because of the presence of an accessory phrenic nerve in 75 per cent of the people studied. s Following nerve injury, appropriate physical and occupational therapy is instituted till maximal return of function has been accomplished.

Results The mortality in the present series was 6 per cent, a figure which is in keeping with the 4 to 11 per cent mortality reported by various authors who have recently treated large series of cases.3-5, 7. 12, 13 Two of the deaths in the present series, involving injuries of the subclavian vein, resulted from ineffective attempts to control hemorrhage via a supraclavicular incision. Emergency thoracotomy with control of bleeding by pressure applied from within the thorax would have been a better approach. These cases emphasize that the major cause of death following penetrating injuries of the neck is hemorrhage. This is a recurrent theme in all reported series, which also emphasize the dangers of inordinate delay in performing surgery and inadequate surgical exploration. Other deaths result from complications or wounds of the larynx, trachea, pharynx, and esophagus, resulting particularly in sepsis or respiratory dysfunction, or from injuries elsewhere in the body.

SUMMARY A series of 50 patients with penetrating Injuries of the neck is presented. All were treated by early exploration of the neck wounds. Thirty patients (60 per cent) had injuries of one or more major structures. The mortality rate was 6 per cent and all patients who died had injuries of major vessels. Injuries to other parts of the body were frequent and occurred in 20 patients (40 per cent). Twenty patients (40 per cent) had penetrating chest injuries. Based on this experience and that of other authors, the following principles of management are advocated. Maintenance of a free airway is essential and may require emergency tracheal intubation or tracheos-

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tomy. Hemorrhage should be controlled by firm pressure over the bleeding area and blood loss should be rapidly replaced. The possibility of injury to the apical pleura should be constantly borne in mind and failure to respond to usual resuscitative measures should raise the possibility of a pneumo- or hemothorax. Prompt tube thoracotomy may prove to be life saving. Even the most innocent looking wound may hide potentially lethal injuries of major blood vessels, the airway, pharynx, or esophagus. All cervical wounds require early surgical exploration. The entire depth of the wound should be explored with definitive treatment of all injured structures. Depending on their severity, treatment of injuries to other parts of the body may take priority over exploration of the neck wound.

REFERENCES 1. Beahrs, O. H., and Devine, K. D.: Treatment of traumatic lesions of the head and neck. SURG. CLIN. N. AMER., 43 :917-927, 1963. 2. Cohen, A., Brief, D., and Mathewson, C., Jr.: Carotid artery injuries. An analysis of eightyfive cases. Amer. J. Surg., 120:210-214, 1970. 3. Fitchett, V. H., Pomerantz, M., Butsch, D. W., Simon, R, and Eiseman, B.: Penetrating wounds of the neck. A military and civilian experience. Arch. Surg., 99:307-314, 1969. 4. Fogelman, M. J., and Stewart, R D.: Penetrating wounds of the neck. Amer. J. Surg., 91 :581-593, 1956. 5. Hubay, C. A.: Soft tissue injuries of the cervical region. Surg. Gynec. Obstet. Int. Abstr. Surg., 111 :511-522, 1960. 6. Hughes, J. T., and Brownell, B.: Traumatic thrombosis of the internal carotid artery in the neck. J. NeuroL Neurosurg. Psychiat., 31 :307-314, 1968. 7. Jones, R F., Terrell, J. C., and Salyer, K. E.: Penetrating wounds of the neck: An analysis of 274 cases. J. Trauma, 7:228-237, 1967. 8. Kelley, W. 0.: Phrenic nerve paralysis; special consideration of accessory phrenic nerve. J. Thoracic Surg., 19:923-928, 1950. 9. Monson, D.O., Saletta, J. D., and Freeark. R. J.: Carotid-vertebral trauma. J. Trauma, 9:987-999, 1969. 10. Penn,1.: Injuries ofthe cervical portion of the thoracic duct. Brit. J. Surg., 50: 19-23, 1962. 11. Penn, I.: Discussion of Fitchett, V. H., et al. Arch. Surg., 99:314,1969. 12. Pont, J. W.: An approach to stab wounds of the neck. Med. Proc., 6:47-53,1960. 13. Shirkey, A. L., Beall, A. C., Jr., and DeBakey, M. E.: Surgical management of penetrating wounds of the neck. Arch. Surg., 86:955-963, 1963. 14. Stein, A., and Seaward, P. D.: Penetrating wounds of the neck. J. Trauma, 7:238-247, 1967. 15. Vandenbos, K. Q.: Management of injuries of the neck. Arch. Surg., 75:721, 1957. 16. Wylie, E. J., Hein, M. F., and Adams, J. E.: Intracranial hemorrhage following revascularization for treatment of acute strokes. J. Neurosurg., 21 :212-215, 1964. 1055 Clermont Street Denver, Colorado 80220