CICM SAQ 2015.2 Q7

a) Describe the anatomy of the root of the neck on the left side describing the clinically important structures that may be injured. (50% marks)

• The root of the neck is the junction between the thorax and the neck. It opens into, and is the cervical side of, the superior thoracic aperture, through which pass all structures going from the head to the thorax and vice versa. The root of the neck is bound laterally by the first rib, anteriorly by the manubrium, and posteriorly by the T1 vertebrae.
• From anterior to posterior, the major contents are:
  • Subclavian artery and branches
  • vertebral artery
  • internal thoracic artery
  • thyrocervical trunk
  • costocervical trunk
  • Subclavian vein and tributaries (EJV)
  • Trachea
  • Oesopahagus
  • Vagus nerve
  • Recurrent Laryngeal nerve Dome of pleura
  • Brachial plexus
  • Lymphatics and thoracic duct
  • Phrenic nerve
  • Sympathetic chain, stellate ganglion
  • Scalene muscle.
  • Clavicle

b) Outline the issues specific to management of a penetrating neck injury. (50% marks)

Requires management at a trauma centre with appropriate expertise. May require multiple speciality input – interventional radiology, ENT, vascular, cardiothoracic.

Airway issues:

• The possibility of laryngeal/ tracheal injury and the risk of intubating the “false airway passage”.
• Consider tracheostomy under local anaesthesia.

Urgent surgical exploration required for haemodynamic compromise, expanding or pulsatile haematoma, extensive subcutaneous emphysema, stridor, or neurological deficit with intra op bronchoscopy/ endoscopy/ angiography if available.

If no indication for urgent surgical exploration requires CT angiography (or equivalent) with close observation in ICU +/- flexible laryngoscopy +/- endoscopy +/- oral contrast swallow study.