Approach to penetrating arterial injury at the base of the neck in an unstable patient

An 18 year-old female arrives to the trauma bay with a gunshot wound at the base of the neck.   EMS states that she has been phonating, but the bleeding has been impossible to control. Her  primary survey reveals a patent airway, decreased breath sounds in the right lung field and an initial BP of 90/60 with sinus tachycardia to 130. Her initial GCS is 13 (E4,V3,M6). She is

intubated for airway protection and a right thoracostomy tube is placed. A brief secondary survey reveals pulsatile, massive hemorrhage originating from a 1x1cm wound at the base of the right neck immediately cephalad to the right sternoclavicular joint. The injury appears to be

medial to the sternal head of the sternocleidomastoid muscle.

 

This scenario raises multiple questions that must be addressed in an extremely timely manner:

• What are the most likely injured structures?
• How do I approach and control those structures quickly in this unstable patient?
• What are the possible side effects of my intervention?
• What are common pitfalls to avoid that have been addressed in the past?

The innominate and right subclavian artery are most susceptible to injury in a wound at the base of the right neck. A median sternotomy is the most optimal approach as it allows for proximal control of the affected vessels as well as gives the best view of the majority of the superior mediastinum. However, in the unstable patient who is actively bleeding, a right thoracotomy will provide timely and ample exposure for immediate direct pressure control of a

right subclavian or innominate artery bleed. A median sternotomy can be performed in conjunction with the right thoracotomy to further enhance visualization. Finally, resection of part of the clavicle with a Gigli saw or a supraclavicular incision will “trapdoor” the right chest, thereby exposing the entirety of the innominate and right subclavian arteries.

Small injuries to the vessels should be repaired immediately. Repair should be attempted in large injuries, but is based on the stability of the patient. In an unstable patient, ligation of the

innominate or subclavian artery is indicated. Predictably, this is associated with significant

morbidity.

 

An injury to the base of the left neck most often compromises the left subclavian artery. Due to its posterior position within the chest, a median sternotomy is not indicated. Instead, a left thoracotomy should be performed as it affords the best exposure for this type of injury.

Traditionally, injuries to the neck were classified into three distinct zones (as documented below) based on entry point at the skin. Unstable, bleeding patients with injuries to any zone are always explored.

 

 

However, stable patients without hard signs of vascular injury (no pulsatile bleeding, expanding

hematoma, bruit or neuro deficit) with injuries to Zones I or III are traditionally imaged with
Angiography/CTA/Esophagoscopy/Esophagram prior to operative planning. Mandatory
exploration was traditionally advocated by many surgeons for all injuries that violated the
platysma in Zone II. This approach proved to be problematic as many wounds (especially GSWs) violate more than one zone regardless of the entry point on the skin. As described in the
drawing, bullets and shrapnel can take a variety of different paths once they enter the neck. However, the advent of helical CT has revolutionized this approach has been shown to have a 100% sensitivity and 96% specificity for diagnosis of vascular or aerodigestive injuries.  (Inaba et al, Journal of Trauma 1996).

This article covers arterial injury at the base of the neck. Other structures that are of concern in a patient with a wound at the base of the neck include the central venous system, nerves, trachea and esophagus. Central venous injury is essentially managed by ligating the offending vessel with knowledge of the morbidity of the ligation. Injuries to named nerves should be repaired primarily or with a nerve interposition from a minor nerve. Injuries to major cranial nerves will be evident on physical exam and injury to the vagus or recurrent laryngeal nerves should be evaluated with direct laryngoscopy. Tracheal injury will be discovered in the primary survey and may require placement of an emergency surgical airway below the level of the
injury. Esophageal injury should be thoroughly investigated with an esophagoscopy and esophageal contrast study.

this post submitted by Dr. Ian Daniel.