Management of Traumatic Soft Tissue and Vascular Injuries to the Neck

Introduction

Patients with evidence of vascular or soft tissue trauma must be approached in a similar fashion as all trauma patients. Primary and secondary surveys initially screen for any imminently life-threatening injuries and guide the acute workup. Occasionally, that survey reveals a vascular injury to the neck requiring immediate surgical exploration, but in most cases, soft tissue injuries are addressed following initial evaluation and stabilization.

Fractures of the facial skeleton, injury of the orbit, pharyngoesophageal perforation, and laryngotracheal trauma must be considered and incorporated into the comprehensive approach to the trauma patient, but the details of the specific management of these injuries are addressed elsewhere in this textbook. Here we focus on the repair of mucosal and cutaneous injury, as well as the evaluation and management of vascular trauma.

Key Operative Learning Points

1.
A comprehensive knowledge of head and neck anatomy is essential in order to approach the wide variety of traumatic injuries.
2.
Soft tissue repair requires meticulous attention to anatomic re-approximation with wound eversion and tension-free closure.
3.
Management of vascular trauma should follow a systematic approach and appropriate application of diagnostic and therapeutic interventions.
4.
The management of certain vascular and soft tissue injuries may require experience and techniques beyond the scope of practice of many head and neck surgeons, and consultation with additional specialists may be required.

Preoperative Period

History

1.
History of present illness
- a.
  Mechanism of injury: This is the single most important piece of historical information and will guide further history taking, physical examination, and workup.
  - 1)
    Determining the type of trauma allows an estimation of forces involved and potential severity of the injury.
    - a)
      Types of blunt trauma: motor vehicle accident, fall, or assault
    - b)
      Types of penetrating trauma: impalement, stab wound, projectile trauma, or gunshot wounds.The type of firearm and projectile should be investigated when possible to estimate the energy transmitted with the injury. A high-power rifle wound, for instance, will cause a greater degree of injury out of the immediate path of the projectile due to concussion and cavitation. Such injuries can be missed on initial evaluation and can result in delayed soft tissue necrosis.
- b.
  Timing of the injury: Prolonged delay will increase the risk of infection following primary closure.
- c.
  Additional historical considerations
  - 1)
    Memory of event/loss of consciousness
  - 2)
    High-volume or pulsatile bleeding prior to presentation
  - 3)
    Restrained or unrestrained, airbag deployment, and the use of a helmet
- d.
  Symptoms that may suggest additional injuries
  - 1)
    Dyspnea
  - 2)
    Dysphonia
  - 3)
    Nasal obstruction
  - 4)
    Changes in vision
  - 5)
    Malocclusion
  - 6)
    Epistaxis/rhinorrhea
2.
Past medical history
- a.
  Medical illness
  - 1)
    Disease states that may affect wound healing or infection risk (e.g., diabetes, immunocompromised states)
- b.
  Prior surgery and anesthesia
- c.
  Family history: bleeding disorders
- d.
  Medications
  - 1)
    Anticoagulants
- e.
  Allergies
  - 1)
    Antibiotics
  - 2)
    Local anesthetics

Physical Examination

1.
Primary and secondary trauma surveys
2.
“Hard signs” of penetrating trauma
3.
Neurologic examination
4.
Signs of skull base injury
5.
Types of soft tissue trauma
- a.
  Lacerations
  - 1)
    Simple, stellate, flap
- b.
  Abrasions
- c.
  Avulsions
- d.
  Burns
- e.
  Bite wounds—human/animal
- f.
  Gunshot and stab wounds
6.
Specific anatomic evaluations
- a.
  Facial skeleton, projection, occlusion
- b.
  Facial nerve function
- c.
  Globe, pupillary response, orbit, eyelid, and lacrimal apparatus
- d.
  Lip, oral cavity, and pharynx
- e.
  Scalp
- f.
  Nasal deformity, septal hematoma
- g.
  Ear

Imaging

None

For simple soft tissue trauma with no evidence of more serious injury and low suspicion based on mechanism of injury, no imaging is required.

Computed Tomography

Computed tomography (CT) imaging is the mainstay of the trauma evaluation. In addition to the standard trauma head and cervical spine CT, noncontrast maxillofacial scans should be considered in patients with evidence of significant soft tissue injury (facial edema and ecchymosis) to evaluate for underlying trauma to the facial skeleton or skull base. A CT scan of the neck with contrast may help to evaluate injury to the upper aerodigestive tract. These studies may also identify orbital hematoma and injuries to the globe.

Computed Tomography Angiography

CT angiography (CTA) should be considered when initial studies have demonstrated evidence of skull base fractures extending close to the carotid canal. It has also become the dominant imaging modality in the evaluation of penetrating trauma of the neck.

Magnetic Resonance Imaging

While magnetic resonance imaging (MRI) may have some value in delayed evaluation of traumatic vascular and soft tissue injuries of the head and neck, its role is limited in the acute and preoperative setting.

Angiography

Four-vessel digital subtraction angiography is the generally accepted modality used in the evaluation of suspected vascular injury to the neck. Traditionally, it was a key part of the classical algorithms for management of penetrating trauma based on anatomic zones of injury. While somewhat controversial, its role in that respect has decreased in favor of more selective use. Over time, endovascular techniques have improved, and angiography as a diagnostic study can be combined with a variety of therapeutic interventions, including embolization and stenting, instead of open surgical exploration.

Duplex Ultrasonography

This modality may be used in the evaluation of the carotid arteries, but subtle signs of injury may be missed, and there is a high degree of interoperator variability.

Indications

1.
Indications for immediate surgical exploration after penetrating trauma; “Hard signs”
- a.
  Shock
- b.
  Pulsatile bleeding
- c.
  Expanding hematoma
- d.
  Unilateral pulse deficit
- e.
  Signs of stroke/cerebral ischemia
- f.
  Bruit or thrill
- g.
  Stridor, hoarseness
- h.
  Extensive subcutaneous air or wound bubbling
2.
Indications for additional evaluation and possible exploration; “Soft signs”
- a.
  History of heavy or pulsatile bleeding
- b.
  Presence of clot
- c.
  Findings on angiography or CTA
3.
Lacerations: P - capitalize to be consistentrimary closure usually indicated
4.
Burns: Operative débridement may be required acutely.
5.
Avulsions and abrasions: initial management usually limited to wound care
6.
Penetrating trauma: Usually left open but partial closure of large wounds may be considered.

Contraindications

1.
Other immediately life-threatening injury
2.
Hemodynamic instability
3.
Contaminated wounds open greater than 24 hours and penetrating wounds
Relative contraindication: Primary closure can be considered, but infection risk is increased. Antibiotics and drains may be appropriate.

Preoperative Preparation

1.
Airway: Evaluate and secure when appropriate.
2.
Control of hemorrhage: Active bleeding should be controlled in the trauma bay or emergency department.
- a.
  For suspected injury to the carotid artery, an assistant may need to maintain manual pressure to prevent exsanguination while proceeding emergently to the operating room. A balance must be struck between adequate pressure to control hemorrhage and the need to maintain cerebral perfusion.
- b.
  Hemorrhage from other soft tissue trauma should be controlled with pressure and dressings. Nasal packing can be used judiciously but with caution if there is concern for skull base injury. If the airway has been controlled, oral and pharyngeal bleeding can generally be controlled with packing. Scalp wounds can result in clinically significant blood loss. Hemostasis can be achieved with pressure dressing or temporary closure with staples or suture until definitive repair is performed.
3.
Trauma resuscitation
4.
Laboratory evaluation
- a.
  Hemoglobin/hematocrit
- b.
  Type and screen
- c.
  Toxicology

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