CHALLENGES
IN
ACUTE CARE SURGERY
A case of internal jugular injury with delayed symptom onset after a stab wound to Zone 1 of the neck Michol A. Cooper, MD, PhD and Elliott R. Haut, MD, PhD, Baltimore, Maryland. With expert commentary by Kenji Inaba, MD
Figure 1. CT of the neck demonstrating a large hematoma compressing the left IJV.
A
29-year-old male was brought via ambulance to our trauma center after being stabbed in the neck and bilateral arms. A primary survey was normal, and he had stable vital signs (heart rate, 101; blood pressure, 175/73). The stab wounds in his arms were superficial, but the one in his left neck was larger and in Zone 1, just above the clavicle. There was no ongoing bleeding or expanding hematoma. A computed tomographic angiogram (CTA) of the neck and chest (Fig. 1)
demonstrated compression of the left internal jugular vein (IJV) due to adjacent hematoma, which extended into the superior mediastinum, as well as air within the left sternocleidomastoid muscle. Because of the air tracking on CT, he was then taken to the operating room to rule out tracheal or esophageal injury with flexible esophagogastroduodenoscopy and bronchoscopy, both of which demonstrated no evidence of injury. However, while being extubated, he coughed,
and 500 mL of blood rapidly came out of the neck wound.
What would you do? A. Immediate surgical neck exploration B. Foley catheter balloon tamponade followed by angiogram and venogram for further assessment of vascular injury C. Foley catheter balloon tamponade and observation with serial hemoglobins D. Direct pressure to control bleeding and angiogram and venogram for
From the Department of Surgery (M.A.C., E.R.H.), Bloomberg School of Public Health (E.H.), Armstrong Institute for Patient Safety and Quality (E.R.H.), and the Center for Surgical Trials and Outcomes Research (E.H.), Johns Hopkins University School of Medicine and Johns Hopkins University, Baltimore, Maryland; and Division of Trauma and Critical Care (K.I.), University of Southern California, Los Angeles, California. Address for reprints: Elliott Haut MD, PhD, Department of Surgery, Johns Hopkins Hospital, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287; email: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 2163-0755 DOI: 10.1097/TA.0000000000000532
J Trauma Acute Care Surg Volume 78, Number 3
652
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Cooper and Haut
further assessment of vascular injury
What we did and why A. Foley catheter balloon tamponade followed by angiogram and venogram for further assessment of vascular injury Immediately after the patient started bleeding from the neck wound, direct pressure was applied with easy temporary cessation of the bleeding. A Foley catheter was inserted into the wound to provide tamponade to temporize the bleeding and allow for evaluation for a venous versus arterial source by interventional radiology (Fig. 2) [1, 2, 3]. Interventional radiology performed a thoracic aortogram with evaluation of the innominate artery, the right and left subclavian arteries, and the right and left common carotid arteries, which demonstrated no evidence of injury. Venography was performed with evaluation of the superior vena cava, bilateral brachiocephalic veins, and the left internal jugular and subclavian veins, which demonstrated a large amount of active venous extravasation from the left IJV close to its takeoff from the subclavian vein. This was best appreciated when the Foley catheter balloon was deflated in the interventional radiology suite (Fig. 3). He was subsequently taken to the operating room for surgical left neck exploration, and a 75% transection of the IJV was found. The vein was ligated; a drain was left in place in the neck. He was
FIGURE 2. Foley catheter balloon tamponade in our patient.
admitted to the surgical intensive care unit where his neurologic examination results remained normal and his hemoglobin remained stable. He was extubated on postoperative Day 1. A cine-esophagogram was normal, and his diet was advanced. The drain was removed, and he was discharged home on postoperative Day 2. At a 2-week follow-up appointment, his neck wound was well healed, with no evidence of further bleeding or wound complications, and he was eating a regular diet without difficulty (M.A.C. and E.R.H.).
Expert Opinion This case very nicely illustrates several important diagnostic and management principles for penetrating injuries to the neck. With no hard signs of vascular (expanding or pulsatile hematoma, active bleeding, bruit or thrill, focal neurologic deficit, or shock) or aerodigestive tract injury (hemoptysis, hematemesis, air bubbling, compromised airway) prompting an emergent trip to the operating room, proceeding to screening CTA is the appropriate next step. For the aerodigestive tract, although the sensitivity of CTA is excellent, the specificity is suboptimal, and it is not uncommon to see air tracking around the esophagus and trachea without a definitive injury. In these cases, as was done, direct visualization using a tailored combination of endoscopy, bronchoscopy, direct laryngoscopy, and contrast swallow is warranted. The primary goal is to ensure that there is no injury to the cervical esophagus. Minor airway injuries that are small enough to not be obvious will likely heal without intervention. For the vascular structures, both the sensitivity and specificity of CTA using newer-generation multislice CT have been shown to be near perfect. In this patient, the CTA demonstrated an intact arterial system. The hematoma, large enough to compress the IJV and located at the level of the stab wound tract, is highly suspicious, if not diagnostic for a major venous injury. Because the patient was asymptomatic, with no external bleeding, the attempt at nonoperative management was acceptable. As a clinical corollary, large caliber percutaneous catheters are routinely removed from the IJV without even follow-up imaging, let alone repair.
FIGURE 3. Active contrast extravasation from the left IJV close to its takeoff from the subclavian vein demonstrated when the Foley balloon was taken down.
In this case however, immediately upon extubation, a large volume of bleeding was noted. The use of balloon tamponade is an excellent method for obtaining local control of bleeding originating from a deep tract. We use large 20 to 22 Fr Foley catheters filled with saline. Often for a large tract, two stacked balloons are required, and if there is a large skin opening, a sharp towel clamp or temporary skin sutures can be used to narrow the skin opening and hold the catheters in place. In the resuscitation bay or even in the operating room when dealing with more lifethreatening torso injuries, this is an excellent temporizing measure. At this point, with the bleeding controlled and resuscitation ongoing, a decision was made to proceed to imaging to evaluate the source, which produced some very nice images. Arguably, an alternative treatment option, which I would have considered, is immediate neck exploration. In this case, there was a CTA demonstrating a large hematoma consistent with an IJV injury, but even without this, with the large volume of bleeding being described, enough to necessitate balloon occlusion, operative exploration and surgical
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
653
J Trauma Acute Care Surg Volume 78, Number 3
Cooper and Haut
control would have been a rapid and safe treatment option. Whether the origin of the bleeding was venous or arterial, the exposure would have been the same. The neck, chest, upper extremities, and groins should be universally prepared for this type of injury to provide access to the intrathoracic segment of the vasculature. It is not uncommon for the injury described to require a sternotomy for proximal control. The IJV was ligated in
654
this case, which is an acceptable treatment for unilateral injury. An esophagogram was performed, presumably to examine swallowing mechanics as direct visualization of the esophagus was performed earlier. The outcome in this patient was excellent. In summary, this case illustrates the diagnostic approach to the patient with penetrating neck injury, which rests on the clinical examination and uses
screening CTA for patients with soft signs of vascular or aerodigestive tract injury. Major venous injuries can be managed nonoperatively in many cases but require close observation, and one should be prepared to intervene emergently. Balloon occlusion is an excellent temporizing measure, but ultimately, this is only a bridge and should not delay rapid exposure and definitive control (K.I.).
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
IN
ACUTE CARE SURGERY
A case of internal jugular injury with delayed symptom onset after a stab wound to Zone 1 of the neck Michol A. Cooper, MD, PhD and Elliott R. Haut, MD, PhD, Baltimore, Maryland. With expert commentary by Kenji Inaba, MD
Figure 1. CT of the neck demonstrating a large hematoma compressing the left IJV.
A
29-year-old male was brought via ambulance to our trauma center after being stabbed in the neck and bilateral arms. A primary survey was normal, and he had stable vital signs (heart rate, 101; blood pressure, 175/73). The stab wounds in his arms were superficial, but the one in his left neck was larger and in Zone 1, just above the clavicle. There was no ongoing bleeding or expanding hematoma. A computed tomographic angiogram (CTA) of the neck and chest (Fig. 1)
demonstrated compression of the left internal jugular vein (IJV) due to adjacent hematoma, which extended into the superior mediastinum, as well as air within the left sternocleidomastoid muscle. Because of the air tracking on CT, he was then taken to the operating room to rule out tracheal or esophageal injury with flexible esophagogastroduodenoscopy and bronchoscopy, both of which demonstrated no evidence of injury. However, while being extubated, he coughed,
and 500 mL of blood rapidly came out of the neck wound.
What would you do? A. Immediate surgical neck exploration B. Foley catheter balloon tamponade followed by angiogram and venogram for further assessment of vascular injury C. Foley catheter balloon tamponade and observation with serial hemoglobins D. Direct pressure to control bleeding and angiogram and venogram for
From the Department of Surgery (M.A.C., E.R.H.), Bloomberg School of Public Health (E.H.), Armstrong Institute for Patient Safety and Quality (E.R.H.), and the Center for Surgical Trials and Outcomes Research (E.H.), Johns Hopkins University School of Medicine and Johns Hopkins University, Baltimore, Maryland; and Division of Trauma and Critical Care (K.I.), University of Southern California, Los Angeles, California. Address for reprints: Elliott Haut MD, PhD, Department of Surgery, Johns Hopkins Hospital, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287; email: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 2163-0755 DOI: 10.1097/TA.0000000000000532
J Trauma Acute Care Surg Volume 78, Number 3
652
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Cooper and Haut
further assessment of vascular injury
What we did and why A. Foley catheter balloon tamponade followed by angiogram and venogram for further assessment of vascular injury Immediately after the patient started bleeding from the neck wound, direct pressure was applied with easy temporary cessation of the bleeding. A Foley catheter was inserted into the wound to provide tamponade to temporize the bleeding and allow for evaluation for a venous versus arterial source by interventional radiology (Fig. 2) [1, 2, 3]. Interventional radiology performed a thoracic aortogram with evaluation of the innominate artery, the right and left subclavian arteries, and the right and left common carotid arteries, which demonstrated no evidence of injury. Venography was performed with evaluation of the superior vena cava, bilateral brachiocephalic veins, and the left internal jugular and subclavian veins, which demonstrated a large amount of active venous extravasation from the left IJV close to its takeoff from the subclavian vein. This was best appreciated when the Foley catheter balloon was deflated in the interventional radiology suite (Fig. 3). He was subsequently taken to the operating room for surgical left neck exploration, and a 75% transection of the IJV was found. The vein was ligated; a drain was left in place in the neck. He was
FIGURE 2. Foley catheter balloon tamponade in our patient.
admitted to the surgical intensive care unit where his neurologic examination results remained normal and his hemoglobin remained stable. He was extubated on postoperative Day 1. A cine-esophagogram was normal, and his diet was advanced. The drain was removed, and he was discharged home on postoperative Day 2. At a 2-week follow-up appointment, his neck wound was well healed, with no evidence of further bleeding or wound complications, and he was eating a regular diet without difficulty (M.A.C. and E.R.H.).
Expert Opinion This case very nicely illustrates several important diagnostic and management principles for penetrating injuries to the neck. With no hard signs of vascular (expanding or pulsatile hematoma, active bleeding, bruit or thrill, focal neurologic deficit, or shock) or aerodigestive tract injury (hemoptysis, hematemesis, air bubbling, compromised airway) prompting an emergent trip to the operating room, proceeding to screening CTA is the appropriate next step. For the aerodigestive tract, although the sensitivity of CTA is excellent, the specificity is suboptimal, and it is not uncommon to see air tracking around the esophagus and trachea without a definitive injury. In these cases, as was done, direct visualization using a tailored combination of endoscopy, bronchoscopy, direct laryngoscopy, and contrast swallow is warranted. The primary goal is to ensure that there is no injury to the cervical esophagus. Minor airway injuries that are small enough to not be obvious will likely heal without intervention. For the vascular structures, both the sensitivity and specificity of CTA using newer-generation multislice CT have been shown to be near perfect. In this patient, the CTA demonstrated an intact arterial system. The hematoma, large enough to compress the IJV and located at the level of the stab wound tract, is highly suspicious, if not diagnostic for a major venous injury. Because the patient was asymptomatic, with no external bleeding, the attempt at nonoperative management was acceptable. As a clinical corollary, large caliber percutaneous catheters are routinely removed from the IJV without even follow-up imaging, let alone repair.
FIGURE 3. Active contrast extravasation from the left IJV close to its takeoff from the subclavian vein demonstrated when the Foley balloon was taken down.
In this case however, immediately upon extubation, a large volume of bleeding was noted. The use of balloon tamponade is an excellent method for obtaining local control of bleeding originating from a deep tract. We use large 20 to 22 Fr Foley catheters filled with saline. Often for a large tract, two stacked balloons are required, and if there is a large skin opening, a sharp towel clamp or temporary skin sutures can be used to narrow the skin opening and hold the catheters in place. In the resuscitation bay or even in the operating room when dealing with more lifethreatening torso injuries, this is an excellent temporizing measure. At this point, with the bleeding controlled and resuscitation ongoing, a decision was made to proceed to imaging to evaluate the source, which produced some very nice images. Arguably, an alternative treatment option, which I would have considered, is immediate neck exploration. In this case, there was a CTA demonstrating a large hematoma consistent with an IJV injury, but even without this, with the large volume of bleeding being described, enough to necessitate balloon occlusion, operative exploration and surgical
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
653
J Trauma Acute Care Surg Volume 78, Number 3
Cooper and Haut
control would have been a rapid and safe treatment option. Whether the origin of the bleeding was venous or arterial, the exposure would have been the same. The neck, chest, upper extremities, and groins should be universally prepared for this type of injury to provide access to the intrathoracic segment of the vasculature. It is not uncommon for the injury described to require a sternotomy for proximal control. The IJV was ligated in
654
this case, which is an acceptable treatment for unilateral injury. An esophagogram was performed, presumably to examine swallowing mechanics as direct visualization of the esophagus was performed earlier. The outcome in this patient was excellent. In summary, this case illustrates the diagnostic approach to the patient with penetrating neck injury, which rests on the clinical examination and uses
screening CTA for patients with soft signs of vascular or aerodigestive tract injury. Major venous injuries can be managed nonoperatively in many cases but require close observation, and one should be prepared to intervene emergently. Balloon occlusion is an excellent temporizing measure, but ultimately, this is only a bridge and should not delay rapid exposure and definitive control (K.I.).
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
