A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON PENETRATING NECK INJURY

1. A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON PENETRATING NECK INJURY BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery

2. General Data: G.M. 28 –years- old Male Sta. Ana, Manila

3. Chief Complaint: Stab wound

4. HISTORY OF PRESENT ILLNESS NOI: stabbing TOI: 2:30 pm DOI: January 1, 2008 POI: Sta. Ana, Manila Few minutes PTC= • Patient was stabbed by an unknown assailant using akitchen knife in the anterolateral aspect of left neck. Patient was then brought to our institution.

5. Past Medical History • No hypertension • No diabetes • No PTB • No previous hospitalization • No allergies to foods and drugs

6. Family History • unremarkable

7. Personal and Social History • unremarkable

8. ABC’s of Trauma

9. Physical Examination • General Survey: • Conscious, coherent, not in respiratory distress • Vital Signs BP = 110/ 60 mmHg CR = 120 bpm RR = 23 cpm Temp: 37 degrees Celsius

10. Physical Examination • HEENT: - Anicteric sclera, pink palpebral conjunctivae, with stab wound on anterolateral aspect of left neck measuring 2 cm in length • Chest: • Symmetrical chest expansion, no retractions, • CBS

11. Physical Examination • Heart Tachycardia, regular rhythm, no murmur • Abdomen flabby, NABS, soft, non-tender

12. Physical Examination • Extremities: • Full and equal pulses, no deformities, no cyanosis

13. Salient Features • 28/Male • Stab wound, anterolateral aspect of left neck with persistent bleeding through the site • Stable BP at 110/60 • Tachycardia at 120 • Clear and Equal BS • No difficulty of breathing

14. Stab wound neck Unstable Stable Operate Asymptomatic Symptomatic Investigate Observe

15. Initial Impression

16. Para clinical Diagnostic Procedure • Do I need to perform a Para clinical diagnostic procedure? “No”

17. Pre-treatment Diagnosis

18. Pre Treatment Diagnosis Stab Wound of the Neck, Zone II, Penetrating, with  Vascular Injury

19. GOALS OF TREATMENT • Neck Exploration • Control of hemorrhage • Identification and repair of injured part

20. Treatment Options

21. Treatment Options

22. Management Neck Exploration, Ligation of Bleeders

23. Preoperative Preparation • Informed consent • Provide psychosocial support • Optimize patient condition • Hydration • Antibiotics • ATS 6000 units TIM ( ) ANST • TT 0.5 ml TIM

24. Operative technique • Patient in supine position under GETA • Asepsis and antisepsis techniques done. • Sterile drapes placed. • Wound exploration done. • Intraoperative findings noted.

25. Operative Findings • 80% transection of internal jugular vein was noted upon exploration

26. Treatment Options 2008 Clinical Practice Guideline: Penetrating Neck Trauma, Eastern Association for Surgery of Trauma

27. Operative technique • Ligation of bleeders done. • Hemostasis secured. • Layer by Layer closure done • Dry sterile dressing placed.

28. Operative technique

29. Postoperative Management • Adequate analgesia • Monitoring of VS and hydration.

30. Final Diagnosis • Penetrating Stab Wound, Zone II, Anterolateral Area of Left Neck S/P Neck Exploration With Ligation of Bleeders.

31. COURSE IN THE WARD • 1st Hospital Day • NPO • Adequate Antibiotic • Adequate Analgesia • DWC

32. COURSE IN THE WARD • 2nd-3rd Hospital Day • GL- Soft diet • Adequate Antibiotic • Adequate Analgesia • DWC

33. COURSE IN THE WARD • 4th Hospital Day • DAT • Adequate Antibiotic • Adequate Analgesia • DWC

34. COURSE IN THE WARD • 5th Hospital Day • Patient discharged

35. PREVENTION AND HEALTH PROMOTION • Advise given to patient regarding • Possible complications • Proper wound care • OPD follow up after 7 days for removal of sutures

36. SHARING OF INFORMATI0N

37. Neck • Zone I- between the clavicles and cricoid cartilage • Zone II-between the cricoid cartilage and the angle of the mandible • Zone III-above the angle of the mandible

38. Algorithm of Penetrating Neck Trauma

39. Journal Appraisal Penetrating neck injuries: analysis of experience from a Canadian trauma centre • Richard W. Nason, MD et. Al. • Trauma and Acute Care Service • Department of Surgery • University of Manitoba

40. Objective • To study the demographics and treatment outcome of penetrating neck injuries presenting to a major trauma centre in order to develop a treatment protocol.

41. Design: • A case review.

42. Setting: • A trauma centre at a tertiary care institution.

43. Patients: • One hundred and thirty consecutive patients who had neck wounds penetrating the platysma and presented to the trauma service between 1979 and 1997.

44. Intervention: • Surgical exploration or observation alone.

45. Main outcome measures: • The location of injury, patient management, number of significant injuries, duration of hospital stay and outcome.

46. Results:

47. Results:

48. Results

49. Results • Neck exploration in 48 asymptomatic patients was negative in 32 (67%). • Significant injuries, including major vascular (12), nerve (13) and aero digestive tract (19) injuries, were identified in 34 patients. • Two of the 130 patients (1.5%) died of major vascular injuries.

50. Results • The mean (and standard deviation) hospital stay for asymptomatic patients treated with observation alone and surgical exploration was similar (3.5 [6.02] versus 4.3 [5.46] days respectively, p = 0.575).