Essentials of General Surgery 5th Ed 2
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Essentials of General Surgery 5th Ed 2
CHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2a highly complex anatomic region with critical vascular, neurologic, and aerodigestive structures concentrated within a very small area. Penetrating injuries to this region of the body are often the result of knife and gunshot wounds. Any wound that violates the platysma muscle carries a risk of inj Essentials of General Surgery 5th Ed 2ury to the great vessels, trachea, esophagus, and spinal cord, and therefore requires further assessment. For purposes of clinical evaluation and manaEssentials of General Surgery 5th Ed 2
gement of penetrating wounds, the anterior neck (from the midline to the anterior bonder of the sternocleidomastoid muscle) is divided into three zoneCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2ricoid cartilage to angle the mandible. Zone ill includes the area of the distal neck, which is from the angle of the mandible to the base of the skull.The management of penetrating injuries has largely evolved from military experience. During World War 1. nonopcrativc management was the standard ap Essentials of General Surgery 5th Ed 2proach but had an associated high mortality due to missed injury. During World War II. the military's policy for management of these highly fatal wounEssentials of General Surgery 5th Ed 2
ds was mandatory surgical exploration, which resulted in a significant reduction in mortality. This experience led to broad acceptance of mandatory exCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2onthera-peutic neck exploration with this policy. A number of authorsbegan to advocate returning to a policy of selective management guided by hard signs and symptoms of injury to the vital structures to reduce the rate of nonthcrapcutic exploration.Initial evaluation of patients with penetrating ne Essentials of General Surgery 5th Ed 2ck wounds is determined by the physical examination and physiologic status. Shock or hard signs of injury to any of the vital Structures in any of theEssentials of General Surgery 5th Ed 2
three zones mandates immediate operative exploration and repair. In the hcmodynamically stable patient, a more selective approach is taken for injuriCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2y require a median sternotomy for adequate exposure and repair of vascular injuries of the thoracic inlet. Similarly, operative exposure to zone III might necessitate disarticulation of the mandible, an osteotomy of the angle of the mandible, or resection of the styloid process to optimally manage a Essentials of General Surgery 5th Ed 2 high internal carotid vascular injury at the base of the skull.Controversy continues to center around hemodynami-cally stable patients with an injuryEssentials of General Surgery 5th Ed 2
located in zone II and no signs or symptoms suggestive of a major injury to a vital structure. Traditional evaluation includes angiography, bronchoscCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2of literature to support the use of contrast-enhanced CT for evaluation of penetrating neck injury. Several prospective studies evaluating the use of CT angiography in penetrating neck trauma have demonstrated a sensitivity approaching 100% and a negative predictive value over 90%. One of the recogn Essentials of General Surgery 5th Ed 2ized limitations of the use of CT in the evaluation of penetrating neck trauma is its difficulty inFIGURE £-23. Zones of the neck.180 • • •ESSENTIALSEssentials of General Surgery 5th Ed 2
OF GENERAL SURGERYdelecting the trajectory of knife wounds, specifically, small pharyngoesophageal wounds are difficult to detect with CT scan. DespitCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2f the anterior neck. This imaging technique is an acceptable method to determine trajectory and thereby triage patients to the operating room, for further diagnostic studies, or observation with serial examination.Aerodigestive Tract InjuryAerodigestive tract injuries arc seen in 10% of penetrating Essentials of General Surgery 5th Ed 2trauma to the neck, optimal airway management is paramount. The translaryngeal endotracheal approach remains the best option, particularly when perforEssentials of General Surgery 5th Ed 2
med by skilled practitioners. The need for a surgical airway (cricothyroidotomy) should always be considered in any patient who might have a difficultCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2l intubation has failed.The preferred method of evaluating for an injury to the larynx and trachea involves a combination of direct laryngoscopy and bronchoscopy. Concomitant injuries are frequent: therefore diagnostic evaluation of possible arterial and esophageal injuries is imperative. Laryngeal Essentials of General Surgery 5th Ed 2injuries are classified as supraglottic. glottic, and subglottic. Supraglottic injuries typically result in a depression of the superior notch of theEssentials of General Surgery 5th Ed 2
thyroid cartilage associated with a vertical fracture of the thyroid cartilage. Disruption of the thyroid cartilage results in a glottic injury. An inCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2e goal due to the higher incidence of stricture formation with delayed repair. Tracheal wounds should be repaired in one layer with absorbable suture. When there is an associated esophageal or arterial injury, the risk of fistulization between the two repairs is reduced by interposing a vascularized Essentials of General Surgery 5th Ed 2 pedicle of omohyoid or sternocleidomastoid muscle. Operative management of cervical esophageal injuries requires meticulous debridement, a two layerEssentials of General Surgery 5th Ed 2
closure of the wound, and closed suction drainage. Injuries limited to the hypopharyngeal region can be safely managed conservatively including a nasoCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2ions exist. The approach is dictated by the patient's hemodynamic status and neurologic assessment, as well as the institutional resources available. Observation or expectant management is advocated for patients who arc comatose. Simple ligation of the artery is an option for those patients presenti Essentials of General Surgery 5th Ed 2ng with exsanguination or when a temporary shunt cannot be placed. The carotid artery should be repaired when the patient has an intact neurologic orEssentials of General Surgery 5th Ed 2
changing examination. Repair may be performed by a direct operative approach or via interventional techniques. Angiointcrvcntion may be particularly aCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2 to the internal jugular vein are the most common vascular injuries with penetrating trauma. In the hemodynam-ically unstable patient, any venous injury should be managedby simple ligation. Otherwise, an injury to the internal jugular vein should be repaired by lateral venonhaphy or patch veno-plast Essentials of General Surgery 5th Ed 2y. Despite the method of repair, subsequent thrombosis is common. Massive air embolism is a rare but highly fatal complication associated with major vEssentials of General Surgery 5th Ed 2
enous injuries. A high index of suspicion needs to be maintained to diagnose this complication.Spinal Cord InjuryApproximately 10% of penetrating neckCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2ed with a high mortality rate. There is no evidence to support the use of steroids in the management of penetrating spinal cord injuries.EXTREMITY TRAUMAExtremity injuries arc quite common in blunt and penetrating trauma and may range in severity from trivial to life threatening. During the primary Essentials of General Surgery 5th Ed 2survey, potentially lethal injuries such as major vascular injuries, open fractures, crush injuries, and near amputations should be identified and addEssentials of General Surgery 5th Ed 2
ressed. History obtained from prehospital personnel may imply significant blood loss at the scene or in transit, and may help expedite resuscitative mCHAPTERcan also occur with a straddle mechanism and have a common association with extraperitoneal bladder injury.PENETRATING NECK TRAUMAThe neck is a Essentials of General Surgery 5th Ed 2vey includes a detailed neurovascular examination of each extremity, with careful evaluation of peripheral pulses, capillary refill time, skin temperature, sensation, motor function, and range of motion. Palpation may elicit tenderness suggestive of fracture or soft tissue injury. Deformity typicall Essentials of General Surgery 5th Ed 2y is associated with fractures, dislocations, or both.Vascular injuries can be obvious or occult. The obvious or "hard signs" of acute vascular injuryEssentials of General Surgery 5th Ed 2
include pulsatile bleeding, an expanding hematoma, bruit, and an extremity that is pale, cool, and pulseless, with paresthesias or paralysis. Hard siGọi ngay
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