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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_970_Библиотеки_им_академика_М_И_Перельмана.pdf
Face and Neck Trauma in an
Austere Setting
Johno Breeze
15 Management of Ballistic
RESOURCE LIMITATION CONCERNS
⚫
Computerised tomography (CT) is essential for
correct management of penetrating face and neck
trauma.
⚫
Surgical intervention should be delayed until CT is
available, unless casualties are haemodynamically
unstable.
⚫
Interventional radiology for penetrating neck
injury (PNI) unlikely to be available – meaning
that conventional access to vascular damage may
be required.
⚫
Such surgery for PNI has potential morbidity and the
need for early exploration should balance the risks.
⚫
Endoscopy is essential for PNI in a resourcelimited environment, even when CT is available.
⚫
Equipment for temporarily stabilising facial
fractures for evacuation is cheap but requires
practice to be performed correctly.
STEP-BY-STEP PROCEDURES
1. Surgical cricothyroidotomy.
2. Arresting facial bleeding by nasal and oral
packing.
3. Access to the common carotid artery in neck
Zone 2.
4. Maxillary–mandibular stabilisation with IMF
screws.
EXSANGUINATING HAEMORRHAGE
Immediate management of penetrating face and neck
injury is based on the modified Advanced Trauma Life
Support principles used by most common militaries, in
which catastrophic haemorrhage precedes the airway.
Multiple types of haemostatic agents are available to
first responders and are highly effective for neck
wounds, especially if pressure is maintained by pressing
on the dressing. In this author’s opinion, combat gauze
type dressings are the most recommended for open
neck wounds, as it not only can be packed without
causing further damage but also easily removed at the
time of surgery. Facial bleeding in comparison can be
catastrophic, and most sources of facial bleeding are
often inaccessible anyway without surgery.
AIRWAY PROVISION
In experienced hands, endotracheal intubation should
be performed even with suspected laryngotracheal
injury. In less-experienced hands – particularly in the
pre-hospital setting – surgical cricothyroidotomy is recommended instead of endotracheal intubation
(Figure 15.1). Intubation can be complicated by the associated expanding neck hematoma, laryngotracheal
injury, and suspicion of an associated cervical spine injury. Specialist kits are available for performing surgical
cricothyroidotomy with a greater lumen diameter than
164 | Fundamentals of Frontline Surgery
Figure 15.1 Clinical image of a pre-hospital placed surgical cricothyroidotomy in situ while in the Emergency
Department.
using a wide bore needle cannula alone. There is no role
for either surgical or percutaneous tracheostomy in
truly acute setting. Should delays in evacuation be anticipated, or if treatment of PNI or facial fractures is
performed, a surgical tracheostomy may be indicated.
STEP-BY-STEP PROCEDURE 1: SURGICAL CRICOTHYROIDOTOMY
⚫
Identify landmarks (Figure 15.2).
⚫
Infiltrate both the skin and through the
cricothyroid membrane with lidocaine and
epinephrine.
⚫
Horizontal puncture through a cricothyroid
membrane with a scalpel – make sure you do not
to hit the posterior wall of the larynx.
⚫
Insert a small lumen endotracheal tube.
⚫
Inflate the cuff and check pressure.
CERVICAL SPINE IMMOBILISATION
The probability of cervical spine instability from a
facial injury from either a GSW or a blast in a patient
who is conscious – neurologically intact and moving
all limbs – is low. Immobilisation is recommended
unless it would place the clinician at risk. There is no
consensus, however, for penetrating cervical wounds,
and most casualties will arrive in a collar, which must
be carefully removed; immobilisation is maintained
during the primary survey.
MANAGEMENT OF FACIAL HAEMORRHAGE
The face is rarely the site of torrential haemorrhage
sufficient to be the sole contributor to hypovolaemic
shock. Bleeding from the nose may represent oral (such
as a mandible fracture) or nasal injury. Similarly, oral
bleeding can represent injuries at both sites. All conscious patients should be sat up and, in extremis, rolled
onto their front. Cauterisation of severe nasal haemorrhage is usually challenging unless a clinician is
well trained, has good light, and ideal magnification.
Instead, nasal bleeding should be managed first by
insertion of a haemostat into each nostril such as
®
Merocel
packing of each nostril should be performed with a
ribbon-type haemostatic dressing; if this fails, then
additional posterior packing should be performed.
or Rapid Rhino®. Should this fail, anterior
Thyroid cartilage
Cricoid cartilage
Laryngeal prominence
Cricothyroid membrane
Management of Ballistic Face | 165
Figure 15.2 Surface landmarks in performing a surgical cricothyroidotomy.
Oral bleeding is far more challenging and may require
intubation. Although bite props can be used to impact
the maxilla, this can displace fractures and should be
performed by an experienced clinician. Oropharyngeal
bleeding that cannot be arrested requires careful
packing that cannot be properly performed without a
definitive airway. Blind clamping of external areas of
facial bleeding should be avoided because critical
structures, such as the facial nerve or parotid duct, are
susceptible to injury. Ligation of the external carotid
artery to stop facial bleeding is rarely successful due to
collateral circulation and is not recommended.
STEP-BY-STEP PROCEDURE 2: ARRESTING FACIAL BLEEDING BY NASAL AND ORAL PACKING
⚫
Identify the source of bleeding.
⚫
If likely nasal bleeding, insert a nasal epistatic into
both nostrils.
⚫
Should bleeding continue, remove both epistats
and pack each nostril with a ribbon-type
haemostatic dressing (Figure 15.3).
⚫
Should bleeding continue, insert a 10–14 French
urinary catheter into each nostril, inflate with
5 mL of air, and pull back until it lodges in the
nasopharynx.
⚫
Although a CT to rule out a base of skull fracture
is taught, in reality, such fractures are far too
small to allow a urinary catheter to pass
through them.
⚫
Repack the anterior nose.
⚫
Any further bleeding is likely to be from
nasopharynx running into the mouth and can
only be addressed by packing the oropharynx.
⚫
This, in turn, requires the patient to be orally
intubated, or through a surgical airway.
DAMAGE CONTROL SURGERY FOR PENETRATING NECK INJURY
Damage Control Surgery (DCS) is a principle where
early identification of life-threatening injuries is
made and the decision to avoid complicated, sometimes lengthy, definitive repairs in an unstable patient. Patients with ‘hard signs’ of PNI should be
taken to the operating room for surgical exploration
prior to CT (Table 15.1). Soft signs include hematemesis, haemoptysis, hoarseness or change in voice,
dysphagia, or odynophagia. In a stable patient, these
signs mandate further evaluation and exclusion of
vascular and aero-digestive injury. Transcervical
gunshot wounds, in particular, have a high probability of underlying damage and, in the lack of
availability of CT, would generally indicate a need for
surgical exploration.
The use of serial physical examinations alone to
guide management decisions in PNI from ballistic
injury is highly debatable and depends on the experience of the clinicians looking after them. For
example, asymptomatic military patients injured by
fragmentation were found to have vascular damage
166 | Fundamentals of Frontline Surgery
Figure 15.3 A Foley catheter (yellow) is inflated within the posterior nasopharynx and haemostatic gauze
packed against it into both nasal cavities.
Table 15.1 Clinical ‘hard signs’ of penetrating neck injury warranting immediate surgical
exploration
Vascular: ongoing bleeding from the neck region that is not amenable to pressure, an expanding
haematoma, and a bruit or thrill in the neck.
Aerodigestive injury: crepitus or subcutaneous emphysema, dyspnoea or stridor, air bubbling from the
wound, tenderness or pain over the trachea, hoarse or abnormal voice, hematemesis, or haemoptysis.
in 25% of cases, even when no wound tract seem to
involve vessel and fragment in close proximity.
Damage to the hypopharynx and oesophagus may
be clinically silent and escape serial physical examinations. Missed oesophageal injuries are the
cause of the majority of delayed complications seen
with penetrating neck injuries. Early signs of oesophageal injury include subcutaneous air, crepitus,
dysphagia, odynophagia, drooling, and hematemesis.
When an oesophageal leak progresses to mediastinitis, morbidity and mortality are significant.
INVESTIGATIONS OF PENETRATING NECK INJURY
Unstable patients and those with hard signs should
proceed straight to DCS. Otherwise, if available, CT
Angiography (CTA) using contrast is recommended
for all but most innocuous injuries, with a Positive
Predictive Value (PPV) of up to 100% for diagnosis of
carotid arterial injuries in experienced units (Múnera
et al. 2000). In ballistic injury, CTA can be nondiagnostic in up to 20% of cases due to metallic
artefact and, therefore, a lower threshold for
exploration will occur. CT is less sensitive for the
diagnosis of injuries to the larynx and trachea.
Flexible laryngoscopy can be performed in intubated
patients either pre- or intra-operatively and can
visualise damage up to and past the carina.
The diagnosis of oesophageal injury in neck injuries
is the most difficult, with CT of 40–79% and NPV of
82–100% (Conradie and Gebremariam 2015; Kazi
et al. 2013; Teixeira et al. 2016). Intra-operative direct
oesophagoscopy (preferably both flexible and rigid)
provide the highest sensitivity for diagnosis of oesophageal injury but requires experience to perform,
especially in a patient with an immobilised cervical
spine. A Gastrografin
can be performed but require a stable, cooperative
®
contrast swallow imaging study
Management of Ballistic Face | 167
patient. When combined, oesophagoscopy with oesophagography has a sensitivity of up to 90%.
THE USE OF NECK ZONES
In the civilian environment where CT scanning and
interventional radiology is readily available, the use
of neck zones to guide management has decreased.
However, in austere settings, particularly when CT is
not available, dividing the neck into three zones still
has a key role. Zone I is classed from suprasternal
notch to cricoid cartilage, Zone II from the cricoid
cartilage to mandibular angle, and Zone III from
mandibular angle to base of the skull. Exercise caution as the neck entry zone may not reflect the trajectory of projectiles once in tissues.
ZONE 1 INJURIES
This zone contains the origin of the common carotid
artery, the subclavian vessels and the vertebral artery,
the brachial plexus, the trachea, the oesophagus
(Figure 15.4), the apex of the lung, and the thoracic duct.
Acute assessment is analogous to chest injury; a chest
radiograph should be taken to exclude haemo- or
pneumothorax. Stable patients with Zone 1 injuries
should be first assessed by CT to guide management.
Since up to one-third of patients with a clinically significant Zone 1 injury may have no symptoms at their
initial presentation, many centres advocate vascular
evaluation of the aortic arch and great vessels, with an
oesophageal evaluation. In a haemodynamically unstable
patient, particularly if polytrauma is present, clinicians
should be sure that the neck is the source of instability
before proceeding to surgery. In the prescribe of instability or hard signs, an incision parallel to sternocleidomastoid is generally utilised (Figure 15.5(a)) and can
be extended into a midline sternotomy (Figure 15.5(b)).
A surgical tracheostomy is recommended in most cases.
ZONE 2 INJURIES
The following structures are located here: the carotid
and vertebral arteries, the internal jugular veins, trachea, and the oesophagus. This zone has comparatively
easy access for clinical examination and surgical exploration. It is the largest zone and the most injured in
the neck. Even in austere setting, stable casualties with
Zone II injuries and no hard signs can be managed
conservatively without surgical exploration until CTA
is available. This is, however, dependent on the mechanism of injury, with authors describing underlying
damage in 78% of asymptomatic ballistic military neck
wounds. Damage to vascular and airway structures in
Zone II should be repaired, with delayed repair of oesophageal injuries generally recommended. Most cases
do not, in fact, require a surgical tracheostomy unless
severe disruption of the larynx or trachea is found requiring delayed or secondary repair. An incision parallel to SCM can be used, but should coexisting facial
fractures be present, a low collar incision is recommended (Figure 15.5(c)); this is analogous to an
incision performed for a neck dissection and enables a
mandible fracture to be fixed externally.
ZONE 3 INJURIES
Zone III is the most challenging to manage, due to its
anatomy and the lack of familiarity of many surgeons
in this era of increasing sub-specialisation. Zone III
contains the distal carotid and vertebral arteries, oroand nasopharynx. The anatomy is challenging to assess clinically and access surgically, due to being close
to the base of the skull and medial to the mandible
(most Zone III injuries are in fact facial injuries).
Casualties with Zone III injuries without hard signs
should have frequent intraoral examination to observe
for oedema or expanding haematoma within the
parapharyngeal or retropharyngeal spaces. Cranial
nerves exiting the skull base such as the glossopharyngeal and hypoglossal are near the great vessels, with
neurological deficits, therefore suggestive of associated
injury. Surgical access to Zone III injuries has been
classically described by extending the sternocleidomastoid (SCM) incision superiorly behind the ear.
However, those injuries medial to the mandible often
require a mandibulotomy to access them. In the author’s experience, surgical access is better managed
through a unilateral collar incision extended into a lip
split to one side of the midline (Figure 15.5(d)). The
mandible is divided using a saw, which may require
tooth extraction. For this reason, even if damage in
Zone II is found on CT, exploration in a stable patient
is best delayed until performed by a surgeon used to
dealing with such injuries. Such injuries in a civilian
setting are generally managed through percutaneous
(a) (b)
(c) (d)
168 | Fundamentals of Frontline Surgery
Figure 15.4 Intra-operative oesophagoscopy used to rule out cervical oesophageal injury. No damage was
seen on pre-operative CT.
Figure 15.5 Operative approaches to the neck include (a) sternocleidomastoid incision, (b) sternocleido-
mastoid incision with sternotomy extension, (c) collar incision, and (d) unilateral collar incision extended into
midline lip split.
angiography, and evacuation of the casualty from
austere setting to a medical treatment facility is highly
recommended.
SURGICAL TREATMENT OF PENETRATING CERVICAL VASCULAR INJURY
The primary objective during operative management is to preserve antegrade flow to the carotid
and vertebral arteries to optimise neurological
function, if possible. Common and internal carotid
artery injuries should be repaired unless there is
truly uncontrollable haemorrhage or devastating
vessel injury. A temporary vascular shunt with a
short piece of plastic can be used while an autogenous graft is harvested to reduce the need for
cross-clamping (Figure 15.6). Ligation of the external carotid and internal jugular is generally well
tolerated unless performed bilaterally. Defects
larger than 2 cm in diameter will often require either a patch or graft; such grafts can come from an
adjacent damaged internal jugular vein, reversed
Management of Ballistic Face | 169
Figure 15.6 Surgical repair of a common carotid artery wound using temporary stent bypass and subsequent
vein graft, as the internal jugular was too damaged to be used.
long saphenous vein or an alloplastic material such
as polytetrafluoroethylene (PTFE). The latter may
save ischaemic time if the artery is temporarily
clamped during repair but has an increased risk
of infection.
Damage to a vertebral artery that is actively
bleeding in an austere environment without access to
endovascular angiographic embolisation requires
surgical exploration. The proximal portion of the
vertebral artery enters the spinal transverse process at
the level of C6. It is usually impossible to get access
distal to that point. The most practical method is to
ligate the vertebral artery at its origin on the second
part of the subclavian and then occlude the vertebral
foramen with bone wax.
STEP-BY-STEP PROCEDURE 3: ACCESS TO THE COMMON CAROTID ARTERY IN NECK ZONE II
⚫
Mark an 8–10-cm skin incision along the anterior
border of the SCM.
⚫
Dissect through skin and platysma to identify
the SCM.
⚫
SCM should be retracted posteriorly to identify
the carotid sheath below, containing the common
carotid artery, internal jugular vein (IJV), and
vagus nerve.
⚫
The IJV is generally superficial to the artery and
should be retracted to one side, or clamped, if time
is critical.
⚫
The key is to obtain proximal and distal control of
the bleeding vessel prior to dissecting the area of
damage.
⚫
The proximal end of the artery should be clamped,
and the area of damage inspected.
⚫
Small holes can be repaired, but larger holes
require a patch or graft.
⚫
Utilise the IJV if required or, if potentially
damaged, harvest a saphenous vein or superficial
femoral vein graft.
⚫
If harvesting a graft, consider a stent to ensure
temporary perfusion is maintained.
SURGICAL TREATMENT OF LARYNGOTRACHEAL INJURIES
Patients presenting with such injuries can be approached using either an anterior SCM or collar incision, although the latter provides greater access.
Most laryngeal defects from penetrating trauma can
be repaired primarily. Although repair is often performed with sutures, small titanium plates used for
midface maxillofacial fractures are often better.
Small defects noted on endoscopy can be managed
non-operatively. If the cartilaginous framework has
170 | Fundamentals of Frontline Surgery
been disrupted beyond management with a primary
repair, delayed repair is recommended, and an endotracheal tube kept in situ. The role of tracheostomy in these patients remains controversial,
with some authors recommending one is placed
distal to large repair. If performed, surgical tracheostomy should be avoided in the area of injury.
The use of temporary stents is, again, controversial
and is not recommended in austere setting.
SURGICAL TREATMENT OF OESOPHAGEAL INJURIES
Surgical repair of oesophageal injuries in austere setting is not recommended if evacuation to a higher
level of care is possible. Unless grossly disrupted, a
nasogastric tube can be passed under endoscopic
guidance to enable feeding. Should repair of a cervical
oesophageal injury be performed, it is best approached through an anterior SCM incision. Should
there be an associated laryngotracheal injury, however,
these combination injuries are best approached
through a collar incision. Maximal exposure of the
oesophagus is achieved through retraction of the
trachea, the thyroid medially and the carotid sheath
laterally. An indwelling nasogastric tube can facilitate
not only the localisation of the oesophagus, but also
the identification of the oesophageal injury through
the instillation of air or methylene blue. Primary
repair is nearly always possible through either a singleor two-layered approach. The main complication from
such injuries is the risks of tracheo-oesophageal fistula, although most of such fistulas will heal without
surgical intervention. Their risk of occurrence can be
minimised by using a tissue flap such as dividing the
clavicular head of the SCM muscle and mobilising it
to separate the trachea and oesophagus. All patients
should remain fed by nasogastric tube only until a
contrast swallow performed at 5–7 days postoperatively has excluded a leak.
SOFT TISSUE FACIAL TRAUMA
Early and aggressive debridement of high-energy facial wounds from ballistic trauma is required to
prevent infection and tattooing of the skin. This is
best undertaken with a surgical scrubbing brush
with an antiseptic solution. Most facial wounds can
be closed within 36 hours after injury, and delayed
closure is rarely necessary. Closed tissues must be
tension free, and if distortion of the tissues is seen,
sutures should be started again. Although local flaps
can be used in the early setting, these are rarely required, and any residual defects should be packed
with an impregnated dressing. Removal of most explosive fragments is actually futile, surprisingly difficult in reality, and of no proven clinical benefit. If
severed branches of the facial nerve or a damaged
parotid duct are encountered, they should be tagged
with a non-absorbable suture for later anastomosis,
unless a clinician with those skills are present. There
is added importance in achieving multiple-layer primary closure in the face, as any leakage of saliva
around a wound will slow healing.
IMAGING OF FACIAL FRACTURES
Plain radiographs, with some limitations, can be
used to diagnose most mandible (lateral obliques
and posteroanterior films) and midface fractures
(occipito-mental films). These are usually supplemented by tomographic radiographs in civilian environment but are unlikely to be available in austere
setting. Therefore, if possible, management should
be delayed following CT imaging and subsequent
three-dimensional bone reconstructions, especially if
comminution or high-energy transfer has occurred.
Missing teeth should be meticulously accounted for
as they represent an airway hazard.
STABILISATION OF FACIAL
FRACTURES WITH
MAXILLARY–MANDIBULAR
FIXATION
DCS of facial fractures comprises temporary reduction and immobilisation of mobile mandible and
maxilla fractures; this can be highly effective in reducing both bleeding and pain (Figure 15.7). Ballistic
facial fractures are often comminuted and open to
both the cutaneous and mucosal surfaces.
Mobile fractures are most effectively stabilised
using upper and lower Erich arch bars (Figure 15.8).
However, such they are time-consuming to place (an
Management of Ballistic Face | 171
Figure 15.7 A LeFort 2 midface fracture visualised with computed tomography including three-dimensional
reconstruction. The whole midface was mobile but was temporarily stabilised using IMF screws and elastic bands.
hour of operating time), require experience to perform correctly, and run the risk of a sharps injury as
they require stainless steel wires. Intermaxillary fixation (IMF) screws are rapid but, again, require practice and there is a risk of damaging tooth roots if
performed incorrectly (Figure 15.9; Jones, 1999).
Once placed, either method should use tight elastic
bands to hold the mandibular teeth to the maxillary
teeth so they can be cut with scissors should vomiting occur (see Step-by-Step Procedure 4).
⚫
Identify the optimal entry position of the screws:
most commonly, this is between the roots of the
first and second premolar teeth in each quadrant.
⚫
Load an 8-mm IMF screw into the specially
designed screwdriver: it is extremely hard to do
this with a conventional screwdriver used for
plating.
⚫
Start to insert the screw – there should be initial
resistance as it threads through cortical bone but
should become easier as soon as cancellous bone is
encountered.
⚫
STEP-BY-STEP PROCEDURE 4:
MAXILLARY–MANDIBULAR
STABILISATION WITH IMF SCREWS
Careful tactile feedback is essential to ensure that
the screw does not go into a tooth root: this is felt
with increased resistance, and the screw should be
withdrawn completely and reinserted from the
beginning.
⚫
Inject local anaesthesia into the vestibule in all
four quadrants: this makes fracture manipulation
and insertion of screws more comfortable.
⚫
The screw should not be torqued, or it may snap:
should this occur, it is best to leave it for
attempted removal by a specialist later.