Neck Injuries- Pathology, Signs And Investigation

The neck has the greatest mortality rate of any body region; Neck injuries are rare.  The risk of mortality rate is around 20.0% of mortality if the range of AIS is greater than 3. 

Penetrating Injury Of The Neck

There are two types of neck injuries: blunt and penetrating injuries.  Impact or other force delivered from or with a blunt item can result in blunt injuries.  When something pierces the body, it can create penetrating injuries.  The structure that determines whether or not we have a penetrating neck injury is the breach of the platysma.

Zones Of The Neck

• Zone I

Zone I contains the esophagus, trachea, and major circulatory systems. It extends from the thoracic inlet to the cricoid cartilage.

• Zone II

Zone II is the largest of the three, with components that are the most surgically accessible, and it is located between the cricoid cartilage and the mandibular angle.This zone is composed of the carotid arteries, jugular veins, and vertebral arteries. The largest structure provides the surgeons with the greatest surgical exposure and access. 

• Zone III

 It is situated between the base of the skull and the mandibular angle.
Surgical access to Zone III's structure is very challenging.

Q. The probable cause of sudden death in the case of superficial injury to the neck is?

Air embolism through external jugular vein

Top Most Points

• The most commonly injured zone is Zone II
• The surgically most accessible zone is zone II
• The surgically least accessible zone is Zone III
• The neck zone associated with the maximum mortality rates is zone I.

Soft Signs Of Neck Trauma

There are two types of signs and symptoms associated with neck injuries: soft indicators and hard signals.  Gentle indications of the neck A neck injury is indicative of a less serious or dangerous injury.  Gentle indications of the neck Hematemesis, hemoptysis, oropharyngeal bleeds, dyspnea, dysphonia, dysphagia, subcutaneous or mediastinal air leaks, non-expanding hematomas, and focal neurologic impairments are among the injuries.

Hard Signs Of Neck Trauma

Severe symptoms suggest that the injury is of a type that requires careful examination and treatment because it poses a significant risk to the patient.
Indicators of severe cervical trauma include the following:

Growing hemorrhage

Severe active bleeding; shock not responding to fluids; reduced or absent radial pulse; cerebral ischemia; vascular bruit or thrill; blockage of the airway 

Management Protocol Of The Neck Injury

When a patient presents with a penetrating neck injury, the first thing to do is determine whether the patient is hemodynamically stable or unstable. If the patient is hemodynamically unstable or experiencing uncontrollable bleeding, no additional testing is required, and the patient is taken straight to the operating room for the exploration.

A patient with symptoms but stable hemodynamics:  Zones should be used to categorize injuries.  A neck or chest CT scan is performed for the zone I damage.  Patients who require more testing undergo bronchoscopy, esophagograms, and CTAs.  A patient is taken for the operation exploration and observations if there are any significant issues. Direct opening and operative exploration are carried out for zone II. 

Proceed with angiography in zone III. In the event of bleeding -> Angioembolization. The patient is hemodynamically stable and asymptomatic.
Complete the esophagogram, bronchoscopy, and CTA on the asymptomatic, zone I patient before proceeding with additional surgery. Choose a trans-cervical gunshot wound (GSW) for zone II. Proceed with angiography. In the event that symptoms exist, proceed with an operation and observation.  In zone III, start the observation process right away if the patient appears to be mostly asymptomatic. 

Blunt Cerebrovascular injury  

The primary causes of blunt cervical vascular injuries (BCVI) are severe flexion-extension movements and seat belt compression.  The severity of bruised cerebral vascular injuries varies from intimal rips, with or without thrombosis, to complete thickness with the development of pseudoaneurysms.
The term "blunt cerebrovascular injury" (BCVI) refers to a group of injuries to the cervical carotid and vertebral arteries caused by blunt trauma.

Pathology

Damage to the arteries and longitudinal stretching are the main causes of damage.  Acceleration-declaration is the mechanism for the most frequent cause of blunt cerebrovascular injuries, which are similar to auto accidents in that they can cause rotation and hyperextension of the neck, stressing the craniocervical vessels.  The carotid or vertebral arteries may be injured by a direct hit to the neck or base of the skull. These injuries are occult, and if left undiagnosed, they may also result in cerebral ischemia, infarction, and death.

The objective of Evaluation

Denver's standards determine it.  The set of screening parameters known as the Denver criteria is used to decide if a neck CT angiography is necessary to identify blunt cerebral vascular damage in trauma patients.

Signs and Symptoms of Blunt Cerebrovascular Injury

 Expanding cervical hematoma; arterial hemorrhage from the mouth, nose, or neck; cervical bruit in patients under 50; focal neurological deficiency; neurological defect not consistent with head CT results; stroke on CT or MRI.

Risk Factors For Blunt Cerebrovascular Injury

High impact on the neck as a mechanism of high energy transfer.  Fractures of LeFort III or II  Breakage of the mandible  A fracture of the complicated skull, basilar skull, or occipital condyle  Any amount of ligamentous injury or fracture in the cervical spine; closed head injury with GCS < 6. 

Closely hanging with brain damage from anoxia Traumatic brain injury with thoracic surgery injuries; clothes line type injury or death belt abrasion with notable swelling, discomfort, or altered mental status. Upper rib fractures; blistering cardiac rupture; and degloving of the scalp. 

Investigation

A CT angiography or DSA should be performed on patients who meet the aforementioned criteria for high risk in order to describe the injury.

If the grade is V, interventional radiologists should be consulted before undergoing surgery or exploring endovascular alternatives.  Angioembolization is carried out after CT angiography.  For other grades, antithrombotic or antiplatelet medication must be initiated; the partial thromboplastin time must be maintained at 40–50 seconds; an angiography must be repeated after seven days.  Therapy is discontinued if the injury heals; if the injury persists, it is continued for three months, and endovascular therapy may be considered.

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