neck vascular injury
Introduction
Introduction to cervical vascular injury Gunshot wounds, stab wounds, cuts, blasts, and car accidents can cause carotid or cervical vein damage. Common types of injuries are side wall injuries, lacerations or fractures, and arteriovenous fistulas can also occur. Symptoms include wound bleeding or cranial nerve dysfunction, local hemorrhage and hematoma. Cervical artery transverse injury, accompanied by signs of severe neurological disorders, even if the surgical repair of arterial rupture, eventually due to cerebral ischemia time is too long and nerve function can not be restored. Therefore, only cases of carotid injury that do not cause severe cranial nerve dysfunction can be achieved after arterial repair. Some scholars have suggested that the internal carotid artery pressure can be measured after blocking the common carotid artery blood flow. If the systolic blood pressure is below 6.67 kPa (50 mmHg), it indicates that the ipsilateral cerebral hemisphere has insufficient blood flow, and the carotid artery should be used inside or outside. The arterial repair is performed by the bypass method. The external carotid artery, vertebral artery or internal jugular vein injury can be treated with ligation. If the internal carotid artery is contused, a cross-anastomosis of the external carotid artery and the internal carotid artery can be performed. basic knowledge The proportion of the disease: the incidence rate of trauma patients is about 0.01% - 0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: thrombosis Aneurysms
Cause
Causes of cervical vascular injury
(1) Causes of the disease
Shrapnel, gunshot wounds, knife wounds, sharp injuries and blunt contusions can damage the blood vessels in the neck. Knife and gunshot wounds are common causes of neck penetration injuries. Carotid sheath and other tissues pass through the anterior triangle. Therefore, it is a dangerous area, and it is easy to cause damage to the blood vessels in this part.
(two) pathogenesis
Compared with the high-speed shrapnel, the low-speed shrapnel has a relatively small degree of damage, while the high-speed shrapnel is highly destructive to the tissue. Secondly, for various reasons, the wear injury is caused by tissue injury. The situation is also different, such as the knife injury generally enters in a straight line direction, such as the length and shape of the knife and the direction of entry, the position of the perpetrator and the injured person, the location of the wound, etc. have certain meaning, the shrapnel injury is generally not a straight line The plane through which the slow bullets and shrapnel penetrate into the tissue may be deflected by the cervical spine and the mandible, and the structure of the blood vessel such as the carotid sheath may cause the bullet to be folded, and the large blood vessel damage caused by the shrapnel is not common unless The shrapnel passes close to the blood vessels in the neck. When the neck is deflected or tilted back, the blood vessels are tightened, and the bullets can directly hit the blood vessels. The pathological changes of the cervical artery injury are directly related to the cause, and most of the arterial lines are directly damaged. A laceration, wearing a wound, but a blunt contusion can also cause damage in the arterial wall. Because of the anatomical relationship, the arteries are often accompanied by veins and nerves, so vascular injuries are often accompanied by nerve damage. Meanwhile arterial injury much more serious than venous injury.
Vascular damage can be divided into three categories:
Vascular wall injury
When the blood vessel is hit by violence and the wall is not broken, it seems to be intact from the surface, but in fact the intima or muscle layer may have been damaged. Although this damage does not have the risk of immediate bleeding, it can cause serious complications, such as Thrombosis, embolism in the distal artery after thrombus detachment, secondary bleeding, pseudoaneurysm and arterial spasm.
2. Injurious arterial spasm
After the arteries are hit by blunt force, the shrapnel rubs or remains on the arterial wall, or the arterial wall is stimulated by the fracture piece. Although the wall of the artery is not broken, it can be sputum, generally limited to the directly injured part, and sometimes it can affect the artery. All of them and their branches, in severe cases can prevent blood flow through, most cockroaches disappear within 24h, generally can be applied with warm wet compress or 1% ~ 2% procaine wet compress, no special treatment, such as persistent If it disappears, it should be lifted. Consider the use of segmental compression dilation to expand the iliac vessels.
3. Blood vessel rupture
When the wound causes the blood vessel wall to be completely or partially broken, according to the degree and nature of the blood vessel damage, it can be divided into three types:
(1) tangential rupture injury: only one side of the arterial wall ruptures, because the crack of the arterial wall is pulled by the contraction of the surrounding elastic fibers and smooth muscles, the rupture not only cannot be reduced, but increases, so the bleeding is not easy to stop by itself.
(2) Piercing rupture: Most of the shrapnel passes through the arterial wall, and the entrance and exit of the arterial wall are worn and wounded. The risk of bleeding is the same as that of the tangential rupture.
(3) Complete transection: When the artery is completely ruptured, the bleeding begins to be severe and the amount is large. However, due to contracture and damaging vasospasm at both ends of the artery, accompanied by blood pressure drop after hemorrhage, thrombosis is easily formed and the lumen is occluded. Therefore, a small arterial rupture does not necessarily cause severe bleeding to death immediately.
Prevention
Cervical vascular 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
Complications of cervical vascular injury Complications thrombosis aneurysms
Vascular injury has the following complications:
1. Bleeding is not limited: bleeding that cannot be stopped is the most serious complication, and the most common cause of death.
2. Hematoma: The hematoma can be gradually enlarged after it is formed, and the breathing is caused by compression of the respiratory tract.
3. Thrombosis: Thrombosis often occurs after vascular repair transplantation. Embolization can cause blood circulation disorder in the brain, causing death or transient central nervous system defects such as aphasia, hemiplegia, vision loss or permanent blindness.
4. Arteriovenous fistula: caused by simultaneous injury of the arteries and veins in parallel, on which continuous murmurs of systolic phase can be heard.
5. Pseudoaneurysm: due to partial laceration of the vessel wall or tearing of the intima layer, blood flows from the defect of the artery to the space of the surrounding tissue to form a hematoma, and the blood-containing space may expand and rupture, or the blood clot becomes mechanized. It becomes the wall of connective tissue and becomes a mass with systolic pulsation (Fig. 4).
6. After the vascular injury of the true aneurysm, the arterial wall of the weak part expands outward, and also has systolic pulsation, but the difference with the pseudoaneurysm is that the blood vessel wall does not rupture, but gradually expands and expands outward, angiography It can be identified that after the filling of the pseudoaneurysm, the emptying is delayed; while the filling and emptying of the true aneurysm is faster.
Symptom
Symptoms of vascular injury in the neck Common symptoms Dyspnea coma varicose systolic murmurs Tinnitus shortness and slow pulse congestive palpitations abscess
Because the type of injury and the location of the neck injury vary, the symptoms are not the same, especially when combined with other organs, the symptoms are complicated.
1. Bleeding: When there is a large amount of bleeding or a huge hematoma that rapidly forms in the tissue surrounding the neck, shock can be caused by acute blood loss, but sometimes a small blind tube injury or a penetrating injury combined with a large blood vessel rupture or perforation may only There are small, even no signs of external bleeding.
2. Neurological symptoms: According to Rubio's 25 years of analysis of 72 cases of acute carotid injury, 25 of them have neurological symptoms, including coma, hemiparesis, aphasia, sputum, total hemiplegia, paraplegia, facial paralysis, etc., but in a coma It is more common to be guilty of sputum, single sputum and hemiparesis plus aphasia.
3. Combined with other organ damage: vascular injury combined with other organ damage, is also common, including trachea, esophagus, heart, pleura, lung, thoracic lymphatic duct, brachial plexus and laryngeal injury, such as subclavian artery injury, Hematoma and brachial plexus damage occurs in the subclavian artery, and the peripheral pulse is lost.
4. Difficulty breathing: due to the expansion of the blood vessels in the neck and the enlargement of the hematoma, the trachea or the laryngeal itself may cause difficulty in breathing.
5. Hematoma: carotid artery and vertebral artery injury, accompanied by or without jugular vein injury, the symptoms of pulsatile hematoma appear on the second day after injury, some on the first 1-5 days after injury or later Appearance, arteriovenous hematoma generally appears earlier than the symptoms of simple arterial hematoma, sometimes a few hours after the injury can hear murmur, and the occurrence of pulsation occurs after the third to fourth days.
When the hematoma is connected to the common carotid artery or internal carotid artery, systolic murmurs can be heard not only in the hematoma, but also in the central and peripheral tissues of the common carotid artery and its branches.
Arterial hematoma is characterized by obvious pulsation, with side headache and radiation ear pain; internal carotid artery hematoma has side optic disc edema and congestion, venous dilatation, and vision loss; when vertebral artery injury, there is no such symptoms, The internal carotid artery hematoma can protrude into the pharyngeal cavity. If it is misdiagnosed as a peritonsillar abscess, the patient can die immediately. If the food is inadvertently eaten, it can cause a lot of bleeding. If the hematoma is not treated in time, it can cause secondary infection. Infection can also cause bleeding and brain complications.
One side of the common carotid artery and internal jugular vein hematoma, due to circulatory disorders can occur hemianopia, or varicose veins of the affected side, arterial contraction and visual loss, the murmur of arteriovenous hematoma is more obvious, not only along the blood vessels, but also away from The injured part hears double noise, and the patient can hear continuous murmur in the neck. This is caused by the conduction of the skull, clavicle and rib. In addition, continuous tremor can be felt locally, and sometimes the pulse can be weakened. And the phenomenon of slow pulse, some cases have vestibular dysfunction and severe headache.
6. Systemic symptoms: severe bleeding, palpitations, shortness of breath, thirst, tinnitus, dizziness, restlessness, panic, pale skin, fast pulse, low blood pressure and other symptoms.
Examine
Examination of cervical vascular injury
After emergency treatment, after the general condition is stable, X-ray examination can be performed.
1. Neck and chest positive, lateral X-rays to understand fractures and shrapnel, the relationship between the retention of foreign bodies and large blood vessels, the upper mediastinum and the posterior pharyngeal space widening and tracheal displacement are also helpful for diagnosis.
Angiography
In particular, it has important diagnostic significance for vascular injury in the deep base of the skull and the lower part of the neck. Because these deep blood vessels will not have external hemorrhage and outward expansion of the hematoma, angiography must be stable in patients, normal blood pressure, no In the case of active bleeding, angiography can also be performed when there is no doubt about the neck and there is a high degree of suspicion. It is also a reliable diagnostic method for complications of vascular injury (such as pseudoaneurysm or arteriovenous fistula). Complications include cerebral embolism, cranial nerve palsy and blindness.
It is very helpful for the diagnosis of vascular injury.
Diagnosis
Diagnosis and identification of cervical vascular injury
History
Have a history of neck trauma.
2. Clinical manifestations
(1) The neck can penetrate the wound to find the entrance and exit. The blind tube injury has only the entrance, no exit, and there is no wound in the neck when the blunt is contused.
(2) There are symptoms such as external bleeding and shock.
(3) If there is a pseudoaneurysm, a contraction murmur can be heard.
3. Auxiliary examination and diagnosis.
4. Determine the diagnosis by exploration
In Flint's 146 cases, of the 206 large vessel injuries, 45 (32%) had no diagnostic signs, but because the site of penetration was close to the large blood vessels, probing was performed and the diagnosis was confirmed.
