Lesión traqueal con reparación de colgajo muscular / Tracheal Injury with Muscle Flap Repair

RESUMEN Los traumatismos en cuello se pueden clasificar las lesiones en contusas y penetrantes, en el caso de las heridas penetrantes las ocasionadas por arma punzocortante son las más frecuentes. Las manifestaciones clínicas dependen del mecanismo del trauma, tamaño y nivel de la lesión. Paciente masculino de 26 años de edad con heridas por arma punzocortante en cuello y muñecas se ingresó a quirófano de urgencia, se realizó una exploración vascular de cuello encontrando una avulsión completa del ligamento cricotiroideo, se realizó la reparación del defecto con un colgajo de los músculos cricotiroideos, cursando una buena evolución es egresado al duodécimo día. El diagnóstico de las lesiones traqueales es desafiante y debe realizase rápidamente. Se debe instalar una vía aérea definitiva de manera eficaz y planear la reconstrucción quirúrgica. El seguimiento postoperatorio realizado de manera interdisciplinaria es esencial para el pronóstico(AU)

ABSTRACT Neck injuries can be classified as blunt or penetrating injuries. Penetrating injuries caused by a puncturing gun are the most frequent. The clinical manifestations depend on trauma mechanism, and on lesion size and degree. We present the case of a 26-year-old male patient with puncture injuries to the neck and wrists. After he was admitted to the emergency room, a vascular exploration of the neck was performed, finding a complete avulsion of the cricothyroid ligament. The defect was repaired with a flap of the cricothyroid muscles. The patient had a good evolution and was discharged on the twelfth day. The diagnosis of tracheal lesions is challenging and must be carried out quickly. A definitive airway should be installed efficiently, as well as the planning of the surgical reconstruction. The postoperative follow-up performed in an interdisciplinary way is essential for the prognosis(AU)

Manejo de las lesiones vasculares en zona I del cuello. Presentación de casos / Handling vascular lesions in the zone I of the neck. Case presentation

RESUMEN Se estima que al menos del 5 al 10 % de todas las lesiones traumáticas del organismo afectan el cuello. En el 30 % de los casos se afecta alguna estructura importante de esta zona del cuerpo humano. Las estructuras vasculares aparecen lesionadas en el 20 % mientras que las estructuras aerodigestivas en un 10%. Las lesiones de la zona I por diversas razones anatómicas y los órganos que incluye son de difícil manejo. Se presentan dos pacientes con lesiones vasculares de la zona I del cuello. Se realizó una revisión del tratamiento de las lesiones traumáticas del cuello con especial énfasis en las de la zona I. Se abordan diferentes tendencias actuales en el manejo de estos pacientes (AU).

ABSTRACT It is appraised that at least 5 to 10 % of all the organism trauma lesions involve the neck. In 30 % of the cases, any main structure of this zone is hurt. Vascular structures are damaged in 20 % while airway-digestive structures are injured in 10 %. The zone I lesions are difficult to handle because of several anatomic reasons and the organs they include. The cases of two patients with vascular lesions in the neck zone I are presented. A review of the treatment of neck trauma lesions was carried out, making special emphasis on the ones in zone I. Several current tendencies in these patients handling are dealt with (AU).

Ruptura traumática de la arteria vertebral por herida penetrante en el cuello / Traumatic rupture of the vertebral artery caused by penetrating neck injury

Introducción: la exanguinación es una entidad clínica dramática que requiere rapidez de pensamiento y acción para obtener buenos resultados.Presentación del caso: se reporta el caso de un paciente de 13 años que sufrió accidente automovilístico y fue atendido en el Hospital Pediátrico Eliseo Noel Camaño , de la provincia de Matanzas, Cuba. El niño llegó con múltiples traumas en miembros superiores e inferiores, y una herida penetrante en el cuello que requirió tratamiento quirúrgico inmediato para controlar hemorragia. Se necesitó un acceso multidisciplinario de intensivistas, anestesiólogos, cirujanos pediátricos, neurocirujanos y cirujanos vasculares, porque la cuantía del sangrado y la localización de la lesión hicieron sospechar una afección traumática de la arteria vertebral. El niño sobrevivió a la lesión exanguinante, y actualmente se encuentra en proceso de recuperación.Conclusiones: la lesión penetrante del cuello puede provocar ruptura traumática de la arteria vertebral, entidad infrecuente que requiere alta sospecha diagnóstica para lograr éxito en su tratamiento. Consideramos vital la visión multidisciplinaria, en la que deben prevalecer maniobras seguras, rápidas y eficientes(AU)

Introduction: exsanguination is a dramatic clinical condition that requires quick analysis and action to achieve good results.Case report: this is a 13 years/old patient who suffered a car accident and was seen at Eliseo Noel Camano pediatric hospital in Matanzas province, Cuba. The teenager had many upper and lower limb traumas and a penetrating neck injury that required immediate surgery to control hemorrhage. It was necessary to involve intensive care experts, anesthesiologists, pediatric surgeons, neurosurgeons, and vascular surgeons because the amount of bleeding and the location of injury aroused the suspicion of traumatic damage of the vertebral artery. The teenager managed to survive from the exsanguinating injury and is currently in his recovery process.Conclusions: the penetrating neck injury may cause traumatic rupture of the vertebral artery, an uncommon condition that requires great diagnostic suspicion in order to succeed in treatment. It is vital to have a multidisciplinary vision in which safe, rapid and effective procedures should prevail(AU)

Trauma cervical penetrante / Penetrating neck trauma

Aim: The aim of this study is to report the surgical outcomes in a series of patients undergoing to exploratory cervicotomy by penetrating neck trauma (PNT) in emergency department of Barros Luco-Trudeau Hospital (BLTH), between 2003 and 2013, in terms of postoperative morbidity (POM). Matherial and methods: Retrospective case series of patient undergoing exploratory cervicotomy in emergency department of BLTH, between 2003 and 2013. The outcome variable was development of POM. Other variables were age, sex, etiology and kind of injury, hemodynamic status at admission, surgical time, distribution of injuries by anatomic areas, need for re operation and intra and post operative mortality. Descriptive statistics were used. Results: During the study period, 59 exploratory cervicotomies were performed to patients with PNT, with an average age of 32,5 years old. 89,8 percent of patients were male. The POM was 33,4 percent, being the most frequent the neurological ones. The most frequent etiology was the stab with 83 percent. 66 percent of patients were hemodynamically unstable at admission. Mean operative time was 107 minutes. The most injured area was the area II. Conclusion: The PNT is a little prevalent disease. The outcomes of our study are consistent with those reported in the literature.

Objetivo: El objetivo de este estudio es comunicar los resultados quirúrgicos observados en una serie de pacientes sometidos a cervicotomía exploradora por trauma cervical penetrante (TCP) en el Servicio de Urgencias del Hospital Barros Luco-Trudeau (HBLT), entre los años 2003 y 2013, en términos de morbilidad postoperatoria (MPO). Material y método: Serie de casos retrospectiva de pacientes sometidos a cervicotomía exploradora en el servicio de urgencia del HBLT, entre el año 2003 y 2013. La variable resultado fue desarrollo de MPO. Otras variables fueron: edad, sexo, etiología y tipo de lesión, estado hemodinámico al ingreso, tiempo quirúrgico, distribución de la lesión según zona anatómica, necesidad de re operación y mortalidad intra y post operatoria. Se utilizó estadística descriptiva. Resultados: En el período en estudio, se realizaron 59 cervicotomías a pacientes con TCP, con un promedio de edad de 32,5 años, de los cuales el 89,8 por ciento era de sexo masculino. La MPO fue de 33,4 por ciento, siendo las más frecuentes las de tipo neurológico. La etiología más recurrente fue el arma blanca con 83 por ciento. El 66 por ciento de los pacientes se encontraban hemodinámicamente inestables al momento del ingreso. El tiempo quirúrgico promedio fue de 107 min. La zona más lesionada fue la zona II. Conclusión: El TCP es una entidad poco prevalente. Los resultados obtenidos en nuestra serie son coincidentes con lo reportado en la literatura.

A 'pen' in the neck: An unusual foreign body and an unusual path of entry.

Penetrating injuries to head and neck region with varying objects have been reported in the literature. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Majority of these injuries occur in interpersonal violence or bomb blasts or road traffic accidents. Despite the improvement in imaging technologies and surgical methods, penetrating injuries to head and neck with impacted foreign bodies are very challenging due to the proximity to vital structures and/or difficulties in accessing them for the removal. [1] Following injury the normal anatomy could be altered because of edema or tissue destruction, which makes the diagnosis or retrieval more difficult. [3] Parapharyngeal or prevertebral space is an unusual place for lodgment of foreign bodies and in these cases the usual point of entry is the oral cavity, cheek or neck. Here, we report a case of a ball point pen extending to the prevertebral region at the level of C1-C2 vertebrae from point of entry at the suprazygomatic region in the temporal fossa.

Conservative treatment in isolated penetrating cervical esophageal injury: case report / Tratamento conservador de ferimento penetrante isolado do esôfago cervical: relato de caso

Non-iatrogenic traumatic cervical esophageal perforations are usually hard to manage in the clinical setting, and often require a careful and individualized approach. The low incidence of this particular problem leads to a restricted clinical experience among most centers and justify the lack of a standardized surgical approach. Conservative treatment of esophageal perforation remains a controversial topic, although early and sporadic reports have registered the efficacy of non-operative care, especially following perforation in patients that do not sustain any other kind of injuries, and who are hemodynamically stable and non-septic. We report a case of a patient sustaining a single cervical gunshot wound compromising the cervical esophagus and who was treated exclusively with cervical drainage, enteral support and antibiotics.

Ferimentos traumáticos do esôfago não iatrogênicos são de difícil manejo clínico e requerem condutas individualizadas e cuidadosas. Frente à baixa incidência dessa afecção, a maioria dos centros não possui experiência suficiente para a definição de uma conduta padronizada para o manejo de tais lesões. O tratamento conservador da perfuração do esôfago permanece um tema controverso, embora relatos mais recentes tenham documentado sua eficácia, especialmente após a perfuração, em pacientes que não apresentam outras lesões associadas, instabilidade hemodinâmica ou sinais de sepse. É apresentado aqui o caso de um paciente com ferimento por projétil no esôfago cervical tratado exclusivamente com manejo conservador, tendo sido realizados drenagem da lesão, suporte nutricional por meio de sonda nasoenteral e antibioticoterapia, com evolução satisfatória.

Tratamiento quirúrgico de fractura cervical en el Hospital Regional Rancagua: análisis de un periodo de 4 años / Surgical treatment of cervical fracture in the Rancagua Regional Hospital: analysis of a period of 4 years

Introducción: La gravedad, las implicancias neurológicas y el alto costo del tratamiento de la fractura cervical, hacen de esta lesión un tema de suma importancia. Esta injuria provoca graves limitaciones e invalidez a los afectados, en su mayoría en plena actividad laboral, impactando en lo médico, social y económico. Objetivos: Describir los pacientes tratados quirúrgicamente de fractura cervical traumática en el Hospital Regional Rancagua, por el equipo de Neurocirugía dentro de un periodo de 4 años. Materiales y Métodos: Se evaluó - 24 pacientes con antecedente de fractura cervical el mecanismo del trauma, el tiempo transcurrido desde el ingreso hospitalario hasta la cirugía, nivel y compromiso de la lesión medular, tipo de abordaje quirúrgico, complicaciones médicas, quirúrgicas y seguimiento post-operatorio, entre otros. Resultados: 5 mujeres y 19 hombres, edad promedio 39 años (rango de edad 14 a 75 años), principales mecanismos de trauma fueron los accidentes automovilísticos-atropello (58 por ciento). El nivel medular más frecuentemente lesionado fue C4-C5 (25 por ciento). En el 50 por ciento de los pacientes se clasificó de entrada como Frankel A, por lo que un 50 por ciento de todos los pacientes ingresaron tetrapléjicos, y de estos, un 33 por ciento egresó tetraparéticos. Del ingreso a cirugía hubo un tiempo de espera promedio 5 días. Dentro de las complicaciones médicas la causa respiratoria (46 por ciento) fue la más frecuente, necesitando 64 por ciento de estos pacientes ventilación mecánica. Se registró 1 infección de herida operatoria donde el abordaje fue posterior. El Índice de Barthel promedio de 14 pacientes fue de 49 puntos. De 6 pacientes con puntaje Cero, 85 por ciento de estos ingresaron como Frankel A y 50 por ciento egresaron tetrapléjicos. Los pacientes se rehabilitaron en promedio de 2.5 meses. Discusión: Logramos objetivar nuestra realidad. La técnica quirúrgica fue prácticamente uniforme entre los pacientes, sin complicaciones...

Introduction: Gravity, neurological implications and high costs of treating cervical fracture, makes of this injury an issue of most importance. This injury causes severe limitations and disability to those affected, mostly in full working activity, impacting on the medical, social and economic. Objectives: To describe patients surgically treated for traumatic cervical fracture at the Rancagua Regional Hospital, by the team of Neurosurgery Department, within a period of 4 years. Materials and Methods: We evaluated 24 patients with an history of cervical fracture mechanism of trauma, the time from hospital admission to surgery, and commitment level of spinal cord injury, type of surgery, medical and surgical complications and follow-up post -operation, among others. Results: 5 women and 19 men, average age 39 years (ranging age from 14 to 75 years), major trauma mechanisms were motor vehicle accidents (58 percent). The most frequently injured spinal level was C4-C5 (25 percent). 50 percent of patients were classified as Frankel A at the admission, so that 50 percent of all patients admitted were quadriplegics, and of these, 33 percent were discharged as tetraparétic. Admission to the surgery were an average of 5 days. Within cause respiratory medical complications (46 percent) was the most frequent, requiring 64 percent of these patients mechanical ventilation. There was only 1 wound infection where the approach was posterior. The average Barthel Index of 14 patients was 49 points. In 6 patients with zero score, 85 percent were admitted as Frankel A and 50 percent egressed as tetraplejic. Patients were rehabilitated an average of 2.5 months. Conclusions: We were able to objectify our reality. The surgical technique was nearly uniform among patients without severe postoperative surgical complications...

Fatores prognósticos nos ferimentos cervicais penetrantes / Prognostic factors of penetrating neck trauma

O pescoço é vulnerável a traumatismos devido à grande quantidade de estruturas vitais, podendo ocorrer lesões importantes e com alta morbimortalidade. OBJETIVO: Avaliar resultados em pacientes vítimas de ferimentos penetrantes cervicais. MÉTODOS: Foram analisados retrospectivamente prontuários de 39 pacientes entre 2001 e 2009. Ferimentos penetrantes foram definidos como lesões que penetravam além do músculo platisma. Foram analisados idade, gênero, etiologia, localização dos ferimentos, estruturas lesadas, tratamento e desfecho. Foi verificada a associação entre essas variáveis e o desfecho (alta ou óbito) por meio do teste exato de Fisher. RESULTADOS: Dos 39 pacientes analisados, 33 (84,62 por cento) eram homens, com média de 28 anos. A principal causa de ferimento cervical penetrante foi projétil de arma de fogo, com 19 (48,72 por cento) casos e a zona mais acometida foi a zona II, com 29 (74,36 por cento). Foram observados 13 (33,3 por cento) casos de instabilidade hemodinâmica e o tempo médio de internação dos pacientes foi de 14 (1-99) dias. A principal indicação da exploração cirúrgica foi a presença de hemorragia profusa em oito (20,5 por cento) dos casos. As principais estruturas acometidas foram veias cervicais (20,5 por cento). Ocorreram oito (20,51 por cento) óbitos. Pacientes jovens apresentaram melhor prognóstico. CONCLUSÃO: A mortalidade foi de 20,51 por cento. Pacientes com menos de 26 anos apresentaram melhor prognóstico.

The neck is vulnerable to trauma because of vital structures and possible major injuries with high morbidity and mortality rates. AIM: To evaluate the outcome in patients with penetrating cervical wounds. METHODS: The medical registries of 39 patients were analyzed retrospectively from 2001 to 2009. Penetrating wounds were defined as injuries that penetrated beyond the platysma muscle. Age, gender, etiology, wound site, injured structures, treatment, and outcome were analyzed. Fisher's exact test was adopted to establish the link between these variables and the outcome (discharge or death). RESULTS: Of 39 patients, 33 (84.62 percent) were men with a mean age of 28 years. The main cause was firearm projectiles - 19 (48.72 percent) cases; the most frequently affected zone was zone II - 29 (74.36 percent). Thirteen (33.3 percent) cases of hemodynamic instability were observed, and the average hospital stay was 14 (1-99) days. The main indication for surgical intervention was the presence of profuse hemorrhage, in eight (20.5 percent) cases. The main structures affected were the cervical veins (20.5 percent). There were eight (20.51 percent) deaths. Younger patients had a better prognosis. CONCLUSION: The mortality rate was 20.51 percent. Patients below age 26 years had a better prognosis.

Manejo del trauma penetrante cervical: serie de casos y revisión de literatura / Management of penetrating neck trauma: case series and review of the literature

Introduction: Penetrating neck trauma is a rare disease, but with high severity that affects the Emergency Room Services. Morbidity and mortality are due to injury of vascular structures and the aerodigestive tract. Conservative or surgical management depends on hemodynamic stability, the affected cervical zone and the presence of clinical signs of alert. Objective: To describe cervical penetrating trauma managed in the emergency unit of the Hospital Base Osorno, between January 2004 and April 2011 and review the literature. Material and Methods: We performed a retrospective review of all patients with penetrating cervical trauma seen at our center in this period. Results: Twelve patients were treated, nine were male. The average age was 29 years, ranging from 4 to 55 years. Zone II was the most affected with 9cases. Eight were stab injuries. The main surgical indications were active bleeding, subcutaneous emphysema and air exiting from the wound. The average length of hospital stay was 3,9 days. One patient died. Conclusions: In our center, penetrating neck trauma is a rare disease, which usually requires a surgical approach, forcing the emergency surgeon to be aware of warning signs to determine the need for surgical exploration or conservative management.

Trauma transfixante: relato de caso / Transfixing traum: case report

Atualmente os traumas por arma de fogo estão cada vez mais comuns, principalmente na população com idadeprodutiva. Lesões cervicais por esse mecanismo são de grande importância por sua morbimortalidade. Suspeitardo diagnóstico e dar o suporte adequado é de extrema importância para salvar a vida do paciente. Nosso objetivo é descrever um caso de ferimento transfixante por PAF em região cervical, com fístula artériovenosa, que obteve um bom desfecho.

Nowadays traumas caused by firearms are more and more common, particularly among working age population. Cervical lesions caused by this mechanism are ofgreat importance for its morbimortality. Distrusting the diagnosis and giving the appropriate support is of the utmost importance to save the life of the patient. Our objective is to describe a case of transfixing wound by PAF in a cervical region, with arteriovenous fistula, which had a good outcome.

Manejo del trauma penetrante cervical de zona II: Hospital Clínico Regional Valdivia: serie de casos clínicos / Penetrating neck injuries of zone II: Hospital Clinico Regional Valdivia: clinical cases

El trauma penetrante cervical de zona II, zona comprendida entre el cartílago cricoides y el ángulo de la mandíbula, que presenta signos de compromiso de una estructura vital, requiere exploración quirúrgica inmediata. La principal controversia, se genera sobre el manejo de lesiones de zona II en pacientes hemodinámicamente estables y sin signos que indiquen daño de estructura vital evidente. Existen 2 conductas: exploración quirúrgica de todas las lesiones que atraviesen el músculo platisma o, tratamiento selectivo que implicaría el examen clínico complementado con estudio por imágenes y endoscópicos que descarten lesiones de resorte quirúrgico. El objetivo de este artículo es presentar una serie de casos de trauma penetrante cervical de zona II en la Unidad de Emergencia del Hospital Clínico Regional de Valdivia entre los años 2002 y 2008 y realizar una breve revisión del tema. Se presentan 7 pacientes de sexo masculino que ingresaron con diagnostico de herida penetrante cervical de zona II, entre 16 y 75 años. De éstos, 4 pacientes sufrieron lesiones por arma blanca, 2 por arma de fuego y I por trauma accidental sobre un cerco. Destaca la presencia de signos duros en los casos de esta serie: 4 pacientes con hematoma expansivo o grande, 2 con aire saliendo por la herida, 1 con disfagia y 1 con ausencia de pulso carotídeo. Se exploraron todos los pacientes. La estadía post-operatoria promedio fue de 8 días y no existieron complicaciones post-operatorias ni fallecidos. La incidencia de este tipo de lesiones en nuestro medio es baja pero de elevada gravedad, por lo que es importante identificar a los pacientes que tienen indicación quirúrgica inmediata de los que Se puede realizar un manejo conservador con el apoyo de métodos de estudio complementarios.

Supraclavicular artery flap "its weightage in reconstructing burn neck contracture"

Flexion contractures of neck are a common sequel of deep burns. Severity varies from discrete linear bands to severe labiomentosternal contractures leading to functional and cosmetic impairment. Use of local flaps can produce best restoration of form and function. This study was meant to analyze clinical utility, advantages and any complications specific to islanded supraclavicular artery flap. This was a descriptive study carried out at department of plastic and reconstructive surgery Mayo hospital Lahore between January 2005 and November 2006. Ten patients presenting with neck contractures with out evidence of trauma in supraclavicular fossae, shoulder and deltoid region were included in the study. History and physical examination details including extent of contracture and cosmetic impairment were endorsed. Essential preoperative workup was done accordingly including assessment by anesthetist. Ten patients with varying severity of neck contractures were included in the study. Age range was 15-35 years. Average hospital stay was 10 days. Five patients had severe labiomentosternal contractures. Eight patients reported neck wound appearing excellent at 6 months postoperatively. In contrast donor area appearance was reported satisfactory by 7 and poor by 3 patients at 6 months. Functional consequences were most with 6 patients having full range of motion [ROM] and 4 patients having limited but satisfactory ROM. There is no reported recurrence so far. Supraclavicular artery based islanded fasciocutaneous flap is a reliable reconstructive tool ideally suited to cover defects in the region of neck to restore form and function

Protocolo de cirugía selectiva en traumatismos penetrantes de cuello / Protocol of selective surgery in penetrating traumatisms of neck

Antecedentes: Los protocolos de exploración sistemática y selectiva de las heridas cervicales tienen similares cifras de morbilidad. Objetivos: Analizar los resultados de un protocolo de explotación selectiva en los traumatismos penetrantes de cuello. Lugar de aplicación: Hospital Público Municipal. Diseño: Retrospectivo. Población: 46 pacientes tratados desde mayo de 1989 hasta mayo de 2004. Método: Atención inicial según normas ATLS. Clasificación topográfica (Roon). Clasificación según la modalidad del traumatismo. Clasificación en grados de severidad de 1 a 4. Exploración inmediata en casos de heridas transfixiantes, hemorragía externa, hematoma, asfixia, estridor laríngeo, esfisema subcutáneo, aerorragia, hemoptisis o hemorragia intratorácica. Zona I: Considerar abordaje combinado. Zona I y II o compromiso neurológico: ecodoppler color o angiografía preoperatoria. Pacientes estables asintomáticos: conducta expectante, radiografía de columna cervical perfil, internación, tránsito faringoesofágico, endoscopias, etc. Lesión ósea o compromiso neurológico: Tomografía computada o Resonancia magnética. Contraindicamos estudios complementarios en pacientes inestables. Resultados: Heridas de arma de fuego: 29 (63%); heridas de arma blanca 14 (30,4%); heridas accidentales: 3 (6,5%). Cervicotomía exploradora inmediata: 21 casos (45,65%). Cervicotomía exploradora luego de observación inicial: 4 casos (8,7%). Exploración con anestesia local: 12 casos (26%). Observación y alta: 9 casos (19,5%). Mortalidad: 2 casos (4,34%). Cervicotomías negativas: 2 casos (4,34%). Morbilidad: 8 casos (17,4%). Conclusiones: Se obtuvieron resultados similares a protocolos selectivos que proponen la exploración de todas las lesiones de zona II, con un bajo porcentaje de cervicotomías no terapéuticas.

Hemangioma deformante cervical derecho: a propósito de un caso / Deformans right cervical hemangioma: a purpose of a case

Masculino de 32 años de edad, con aumento de volumen progresivo en la cara lateral derecha del cuello, de 20 años de evolución. Se sometió a resolución quirúrgica sin complicaciones. La histopatología reveló un Hemangioma Cavernoso, un tumor vascular benigno poco común, que puede causar molestias estéticas y funcionales de acuerdo a su localización, así como complicaciones sistémicas relacionadas con síndromes asociados. Comúnmente aparece en etapa neonatal puede hacerlo en el adulto. No existe tendencia a la regresión. La cirugía es el tratamiento definitivo, siempre que la lesión sea circunscrita y no afecte a órganos vitales.