open neck injury
Introduction
Introduction to open neck injury The neck contains cervical vertebrae, pharynx, larynx, trachea, esophagus and important blood vessels and nerves. There are mandible, sternum, clavicle, shoulder and cervical vertebrae to support and protect, but its open injury is still not uncommon. Open neck injury (openinjuryofneck) can often cause partial or complete rupture of the laryngotracheal, pharyngeal esophagus, cervical ridge, and cause cervical emphysema, pneumothorax, hemothorax and even pericardial tamponade and hemorrhagic shock, etc., the condition is very dangerous, death The rate is 2% to 10%. Therefore, immediate first-aid treatment must be carried out, and the cervical vertebra should be protected during transport to prevent further damage. basic knowledge The proportion of illness: the incidence of this disease in a car accident is about 0.03--0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: Cellulitis Esophageal injury Abscess Blood aorta Arrhythmia Pneumonia Aspiration pneumonia Aneurysm Thrombophlebitis Shock Swelling Meningitis Esophageal scarring Osteomyelitis
Cause
Cause of open neck injury
(1) Causes of the disease
The factors that cause the open injury of the neck are mostly cut wounds and penetrating injuries. Usually, they are injured by sharp instruments (self-injury and injury), and most of them are wounded by firearms (bomb and shrapnel, etc.).
(two) pathogenesis
The neck injury is usually in the area of the ring, and the neck is the most. The neck injury can be divided into three areas according to the anatomy: the I area is the sternal fossa to the ring cartilage; the second area is the ring cartilage to the mandibular angle. Between; the zone III is the mandibular angle to the base of the skull.
Different lesions, pathological changes are also different, common pathological changes are:
1. Laryngeal trachea, pharyngeal esophageal continuity interruption
The continuity is destroyed, and the laryngeal cartilage fracture can be displaced, and the anterior and posterior larynx diameter becomes shorter, the glottic closure is abnormal, the laryngotracheal tube, the pharyngeal esophagus soft tissue edema, or the submucosal hematoma escape from the laryngotracheal or pharyngeal esophageal rupture. The air is not discharged smoothly, or the irritating cough can cause gas to directly enter the neck connective tissue space and subcutaneous tissue, subcutaneous emphysema, mediastinal emphysema and even cardiac tamponade.
2. Pleural rupture
If the rupture is not quickly blocked by the clot, connective tissue or ruptured muscle, the air will enter the pleural cavity, affecting the respiratory movement of the lungs, not much gas, limited breathing, and difficulty or slight breathing difficulties. If the apical rupture of the pleura is not occluded, it is easy to enter the pleural cavity during inhalation. When the air cannot escape during exhalation, the pressure in the pleural cavity gradually increases, forming a tension pneumothorax, compressing the lung tissue and causing mediastinal orientation. The healthy side shifts, at this time, the gas exchange is seriously impeded, and when a large amount of bleeding occurs, it also causes the blood chest.
3. Cervical dislocation and spinal nerve injury.
Prevention
Open neck injury prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Open injury to the neck Complications Cellulitis Esophageal injury Abscess Thoracic arrhythmia Pneumonia Aspiration pneumonia Aneurysm Thrombophlebitis Shock Swelling Meningitis Esophageal Scarring Stenosis Osteomyelitis
1. Deep neck tissue and organs and systemic infections
When the pharyngeal esophagus is damaged, it is easy to have cellulitis of the neck, abscess in the parapharyngeal space, abscess in the posterior pharyngeal space, submandibular gland inflammation, progressive peri-esophageal inflammation, abscess around the esophagus, neck pharynx, laryngotracheal fistula and esophageal trachea, etc., bacterial toxins absorbed into the blood can cause sepsis.
2. Hemothorax and pericardial hemorrhage
A large amount of bleeding along the interstitial space into the chest and pericardium, etc., can lead to embossing of the lungs and heart, dyspnea, arrhythmia.
3. Respiratory infection
Oral secretions, vomits are inhaled into the airways, causing bronchial pneumonia and aspiration pneumonia.
4. Aneurysm, pseudoaneurysm, arteriovenous fistula and cervical venous thrombophlebitis.
5. Nerve damage
Spinal nerve or spinal cord transection due to cervical vertebrae displacement or local swelling, or carotid injury and hemorrhagic shock can cause spinal nerve and brain damage, such as cerebral ischemic nervous system dysfunction after shock, Vocal cord sputum, VII, IX, XI, XII cranial nerve injury, diaphragmatic spasm, Horner syndrome, brachial plexus palsy, cerebral ischemic hemiplegia after carotid artery injury, high paraplegia and meningitis after cervical spinal cord injury.
6. Glottic scarring, tracheal and esophage scarring and so on.
7. Skeletal complicated with cervical osteomyelitis and clavicular osteomyelitis.
Symptom
Open neck injury symptoms common symptoms edema esophageal fistula open injury sensory disturbance cervical spinal cord complete injury sternocleidomastoid muscle swelling cough limbs high paraplegia tension pneumothorax
Laryngeal tracheal injury
An open injury to the midline of the neck or near the midline has the potential to damage the laryngotracheal tube.
(1) outgassing, loss of sound: the wound has bubbles in the wound, or there is hoarseness or loss of sound. If the laryngeal cartilage fracture is displaced, the normal outline of the throat is unclear, and the anterior and posterior diameter of the larynx becomes short, so that hoarseness can occur immediately. Loss of sound, because the fracture pieces overlap, the vocal cords move to the outside, the glottis is incompletely closed or completely unable to close, resulting in a large amount of air loss, losing enough air pressure under the glottis, at this time only breathable voice.
(2) difficulty in swallowing, limited head rotation: dislocation of the sacral cartilage and snoring or loss of sound in the glottic or glottic upper and lower hematoma, sometimes throat snoring during inhalation, patients often complain of swallowing pain, difficulty swallowing, coughing weakness Can't turn the head.
(3) Difficulty breathing: due to inhalation of blood, saliva, vomit and broken tissue pieces, or due to foreign body obstruction, laryngeal, tracheal cartilage fracture displacement, laryngeal edema, laryngeal submucosal hematoma, etc., may have difficulty breathing, sometimes Progressive.
(4) subcutaneous emphysema and mediastinal emphysema: the neck is swollen, can be licked to the sputum pronunciation, severe cases of subcutaneous emphysema in the neck can be extended upwards and downwards, up to the hairline, down to the chest wall, abdominal wall, or even the whole The trunk, up to the upper limbs, the gas in the neck tissue space can be extended to the mediastinum to form mediastinal emphysema and pneumothorax. Severe mediastinal emphysema can hinder the reflux of the vena cava blood, affect blood circulation, and then have difficulty breathing.
The innocence of the neck was innocent, and the anterior sternum disappeared in the percussion. The X-ray of the lateral sternum showed air behind the sternum.
(5) cardiac tamponade: air in the mediastinum can also enter the pericardial cavity, causing cardiac tamponade. At this time, the patient's venous pressure rises, the heart sounds weaken, the blood pressure drops, the pulse slows, and the heart becomes larger.
Mediastinal emphysema, pneumothorax or cardiac tamponade can cause rapid death of patients, should be detected early, timely evacuation or drainage before the upper mediastinum, and chest surgery urgent consultation, to make appropriate treatment to save the lives of patients.
(6) Physical examination:
1 In the early stage of the displacement of the laryngotracheal cartilage fracture, the laryngeal cartilage is flattened or collapsed on one side, and the normal sign of the larynx disappears; the incision and larynx on the thyroid cartilage disappear during percussion; sometimes the frictional sound of the broken cartilage can be found, or can be touched Clear fracture displacement.
2 When the subcutaneous emphysema is swollen in the neck, it can be pronounced in the sputum. Anyone with subcutaneous emphysema in the neck should be alert to the presence or absence of mediastinal emphysema.
3 to determine the laryngotracheal injury, such as the cutting injury, should be from the open wound, to understand the degree of cartilage injury, the degree of rupture of the laryngotracheal tube and the withdrawal of the tracheal stump.
The trachea can sometimes be completely detached, retracted upwards and downwards, and the trachea contracts downward, which presents severe dyspnea and cyanosis. Those with laryngotracheal injury, coughing when swallowing, may cause food to fall into the respiratory tract, or cause tracheoesophageal fistula. .
2. Pharyngeal tube injury
(1) hematemesis, difficulty swallowing: vomiting blood, hematemesis, swallowing pain and difficulty swallowing when the esophagus ruptures.
(2) Leakage, air leakage: saliva when swallowing, food or air can leak from the pharyngeal esophageal rupture, and there may also be subcutaneous emphysema, pneumothorax and mediastinal emphysema.
(3) Infection: The pharyngeal esophageal injury is easily complicated by deep neck or mediastinal infection.
(4) Physical examination: clear the condition of the pharyngeal esophageal injury. If the pharyngeal esophagus is not diagnosed, the sterile soft saline can be used to inject into the soft tissue wound of the neck, so that the patient can swallow the mouth and the air bubbles in the neck wound escape. It indicates that there is rupture of the pharyngeal esophagus, and the patient may be swallowed with a purple or methylene blue solution. If the color of the neck is found to have a dye color, it means that the pharyngeal esophagus is broken. The fiber esophagoscopy can directly observe the pharyngeal esophageal injury. Happening.
In the cutting injury, it is easy to find the broken mouth, sometimes the esophagus is completely cut off, and the cervical vertebrae can be seen in the depth of the incision when the upper and lower receding is reversed, but the pharyngeal esophageal rupture caused by the neck penetration injury is sometimes easily overlooked, and even needs to be done. The neck can be found by exploration.
3. Vascular injury
See general surgical neck vascular injury.
4. Chest catheter injury
The thoracic duct starts from the chyle pool in front of the second lumbar vertebral body. It is formed by the combination of the left and right lumbar trunks and the intestines. It is inserted into the thoracic cavity upwards, and is advanced along the front of the spine between the azygous vein and the thoracic aorta. To the left neck, the left venous angle is merged (Fig. 3). Therefore, when the thoracic duct is ruptured above the fifth thoracic vertebra, the left chylothorax occurs, and when the fifth thoracic vertebra is ruptured, the right chylothorax appears.
When the left neck is damaged, it is easy to have a chest tube injury. At this time, the wound may have chyle outflow, or the chyle solution may be taken out when the pleural puncture is diagnosed, or the thoracic catheter injury may be found when the neck is incision exploration. The amount of damaged chylorrhea can reach 1~3L within 24h, containing high fat and high protein, which often causes severe dehydration and malnutrition in patients. A large amount of chyle in the pleural cavity can cause severe breathing difficulties. .
5. Thyroid damage
In patients with cut wounds, it is easy to detect that the gland may be cut or partially cut off; but the injury is often found in the neck when the incision is discovered, the thyroid is rich in blood vessels, and the blood is lost after the injury. More, and easy to form a hematoma, and even cause suffocation.
6. Salivary gland damage
It can injure the submandibular gland or parotid gland, and there is saliva in the wound, but no foam.
7. Pleural apex injury
The main manifestation is that the respiratory tract is unobstructed, but there is difficulty in breathing. If you have a pneumothorax or blood pneumothorax, the lungs may be restricted in breathing. The breathing difficulties may not be obvious. You only need to observe them closely. No special treatment is required. For example, there is a lot of air entering the pleural cavity. Difficulty breathing is obvious. The air or blood in the pleural cavity should be taken out to form a tension pneumothorax with mediastinal shift. The patient's breathing is extremely difficult, the hair is weak, and the condition is very critical. Blood should be drawn immediately and then closed. Chest drainage to save the lives of patients.
8. Cervical spine injury
Light can be asymptomatic, or complain of mild neck pain, head and neck remain fixed position, movement is impeded, cervical vertebra may have tenderness, cramps or deformities, cervical spine injury is severe, high paraplegia (four limbs), or below the injury There is a sensory disturbance in the spinal nerve distribution area.
For patients suspected of cervical spine injury, be careful to move, the head position should be fixed when transporting, do not over-head, so as not to increase the damage of the spinal cord, resulting in sudden high paraplegia or death.
9. Guilloja or clavicle fracture
There are local swelling, congestion or deformity, etc., there is tenderness, bone friction or overlap of the bones, severe pain when swallowing, and increased pain when the tongue is extended, which is a feature of hyoid bone fracture.
10. Inspection of combined injuries
When the neck is open, it often combines with other parts of the composite injury, and should be checked together with the relevant departments.
Examine
Examination of open neck injury
X-ray inspection
(1) Lateral chest radiograph: In the case of mediastinal emphysema, the X-ray of the lateral sternum shows the presence of air behind the sternum.
(2) cervical X-ray film: can help to rule out whether there is cervical displacement and fracture.
(3) Head and neck X-ray film: When there is a suspected hyoid bone fracture, the head and neck X-ray film can assist in diagnosis.
(4) CT scan.
(5) Perform neck angiography if necessary.
2. Fiberoptic esophagoscopy
In the diagnosis of pharyngeal esophageal injury, fiber esophagoscopy can be performed to directly observe the damage of the pharyngeal esophagus.
3. Indirect laryngoscopy, fiber laryngoscopy and bronchoscopy
Suspected laryngotracheal rupture, laryngeal cartilage fracture and subcutaneous emphysema, etc., can be performed indirect laryngoscopy, fiber laryngoscopy, or bronchoscopy to assist in diagnosis.
Diagnosis
Diagnosis and diagnosis of open neck injury
History
Have a history of neck trauma.
2. Clinical manifestations
There is an open wound in the neck; the wound is out of breath; the patient has a voice with difficulty in swallowing, difficulty in breathing, etc., abnormal head movement, subcutaneous emphysema, pneumothorax, spinal nerve injury and other signs.
3. Auxiliary examination and diagnosis.
