Damage to blood vessels in the neck. How to act in case of injury to the carotid artery Injuries of the larynx and trachea
Neck injuries are rare in peaceful conditions. More often they have a chipped or cut character; not great in length. Open neck injuries most often include wounds inflicted by a sharp or piercing weapon, such as bayonet wounds, knife wounds, and gunshot wounds in peacetime or war. These wounds may be superficial, but can affect all anatomical elements of the neck.
Cut wounds to the neck
Among cut wounds of the neck, a special group consists of wounds made for the purpose of suicide. The wounds are often inflicted with a razor and are usually the same in direction - they go from the left and from above to the right and down, for left-handers - from the right and from above. These wounds vary in depth, often penetrating between the larynx and hyoid bone, usually without affecting the main vessels of the neck.
Gunshot wounds to the neck
When diagnosing neck wounds, the most alarming symptom is bleeding. Such combined injuries are explained by the fact that on the neck there are a large number of vessels in small spaces in different topographic layers. Especially many arteries and veins are concentrated in the supraclavicular fossa, where several blood trunks may be injured. It should be noted, however, that the wounded with such injuries remain on the battlefield. The topography of the injury makes it possible to assume which vessels and organs of the neck may be injured in this area.
To clarify the diagnosis, in addition to examining, palpating and determining the functions of the neck organs, mirror and direct tests are used. Auxiliary methods - fluoroscopy and radiography - can significantly clarify the diagnosis.
Isolated neck wounds in war were less common than combined wounds of the neck and chest, neck and face. In the latter combined lesions, wounds to the pharynx were detected in 4.8%, and wounds to the esophagus - in 0.7% of all neck wounds. Only with stab wounds and gunshot wounds are sometimes isolated wounds of the cervical part of the esophagus, both in peacetime and in wartime. Along with the esophagus, the trachea, large vessels of the neck, nerve trunks, thyroid gland, and spine with the spinal cord are often damaged.
Injuries of the larynx and trachea
With significant wounds of the neck, these do not present any difficulties for diagnosis, because these holes usually gape. With minor wounds, escaping air, emphysema of the subcutaneous tissue, and difficulty breathing are important for diagnosis.
Treatment. Tracheal wounds should be sutured under appropriate conditions. In case of injury, it is advised to apply sutures in such a way that they cover the hyoid bone and pass through the thyroid cartilage; the best suture material in these cases is nylon thread. If the larynx or trachea is completely cut, then both sections are connected with sutures or along their entire circumference, or the middle part of the wound is left open to allow the insertion of a tracheostomy tube. If the wound is located in an inconvenient location for tracheostomy, the latter is applied in the usual place. For preventive purposes, tracheostomy should be used more widely, providing the patient with free breathing.
In these wounds, special attention should be paid to stopping bleeding, since leakage of blood can lead to suffocation. If a large amount of blood has poured into the trachea and the patient cannot cough it up, it is necessary to suck out the blood using an elastic catheter or tube. In cases of difficulty breathing after tracheostomy, the larynx is tamponed above the tube or a special tampon tube is inserted to prevent further blood flow into the lungs.
Incised wounds of the cervical esophagus
Incised wounds of the cervical part of the esophagus are observed in suicides, who simultaneously injure other important organs in the neck along with the esophagus. With this type of wound, the mucous membrane of the esophagus is often not affected and protrudes outward through the cut muscle layers.
Treatment. In case of combined injuries, urgent measures are taken against life-threatening situations associated with simultaneous damage to blood vessels and the windpipe. As for the esophagus, the main danger is the penetration of infection through the wounded wall. Therefore, after an injury to the esophagus, a patient is prohibited from swallowing for 2-3 days. At this time, subcutaneous or intrarectal drip administration of saline or 5% glucose solution is prescribed. Nutrient enemas may also be used. The position of the wounded person on the bed should be with the lower limbs strongly elevated to protect against the possibility of numbness.
The neck wound is widened, a temporary dense tamponade of the esophageal wound is performed, all adjacent affected organs are treated - the blood vessels are ligated, and the airways are restored. After this, the peri-esophageal space opens wide. Sutures are placed on the esophagus, especially with fresh incised wounds. For heavily contaminated wounds, the hole in the esophagus is sewn into the wound. A soft tampon is applied to the peri-esophageal tissue, as in the case of a cervical one. For complete unloading of the esophagus and nutrition of the patient, gastrostomy is recommended. Restore, if possible, the muscles and fascia of the neck.
Injuries to the cervical spine
Combined injuries of the spine in the neck, according to a specialized hospital, during the war of Ukraine against the Russian occupiers were determined to be 3.7%. According to neurosurgeons, the frequency of such injuries was 1.75% of all spinal injuries.
In case of combined injuries of the spine in its upper part, slight tangential injuries to the bodies of the 1st and 2nd vertebrae without pronounced neurological disorders were observed. In the first days after injury, mild meningeal-radicular syndromes were observed.
Severe injuries of the spine are accompanied by damage to the membranes, roots, and sometimes the spinal cord. In most cases, such wounded died on the battlefield or in the most advanced stages of evacuation from shock, respiratory failure or life-threatening bleeding.
In survivors of combined injuries, the posterior parts of the spinal column were most often damaged, often with opening of the spinal canal. Less commonly, the anterior and lateral parts of the spine were affected, i.e., the vertebral bodies, transverse processes, and even less frequently the articular processes. With such injuries, the spinal canal is rarely opened and the spinal cord is not directly injured, but only bruised and concussed (see Diseases of the spinal cord).
Neurologically, with these injuries, radicular phenomena in the form of mild hypoesthesia within the damaged segments can be detected in the earliest stages.
Diagnosis. Limiting the mobility of the neck and studying the course of the wound canal allows one to suspect a spinal injury. Sometimes early diagnosis is helped by the appearance of Horner's symptom due to damage to the cervical part of the borderline sympathetic trunk, as well as digital examination of the posterior pharyngeal wall (infiltration of prevertebral tissues).
With axial loading of the spine, pain is detected. X-ray examination clarifies the diagnosis. If the two upper cervical vertebrae are damaged, a frontal photograph is taken with a special tube through the open mouth.
After spinal injuries in the late stages, gunshot osteomyelitis occurs in more than 50% of cases. The frequency of osteomyelitis in the cervical spine is associated with the high mobility of this part of the spine, the peculiar location of the wound channel, the wide opening of which is prevented by the proximity of the neurovascular bundle, the vital organs of the neck. Infection of the vertebrae with osteomyelitis often occurs due to communication between the wound canal and the oral cavity.
Treatment of wounds based on the experience of wars remains largely conservative and comes down to immobilization of the neck and head with a removable plaster collar, cardboard collar or soft Shants collar, the prescription of antiseptics, and physical therapy - UHF, quartz.
All these measures are designed to prevent purulent complications. If osteomyelitis occurs and after removal of the sequestra, the orthopedic collar cannot be removed for up to 18 months.
For a surgical approach to the cervical vertebrae using method 3. I. Geimanovich, the most convenient way is obtained by making an incision along the posterior edge of the sternocleidomastoid muscle. To expose the lower cervical vertebrae, it is more convenient to walk along the anterior edge of this muscle, then highlight the anterior surface of the scalene muscles; When approaching the vertebrae, it is necessary to take into account the topography of the brachial plexus.
To access the upper 3-4 cervical vertebrae, I. M. Rosenfeld used transoral dissection of the posterior wall of the pharynx.
K. L. Khilov, considering transoral sequestrotomy insufficient, developed access to the arch of the first cervical and the bodies of the second and third cervical vertebrae.
The outcomes of combined wounds of the cervical spine during the Great Patriotic War were satisfactory, while those wounded with similar lesions in the war of 1914 rarely survived.
Combined injuries of the spine, pharynx and esophagus
Such wounds have a very high mortality rate. For such wounds, the following method may be recommended: a probe inserted through the nose and passed below the esophageal defect provides feeding to the patient, protects the neck wound from leaking, and serves together with the prosthesis around which the mobilized esophagus is formed. At the same time, measures are taken to eliminate the osteomyelitic focus to stop the progression of the bone process and the further development of infection in the tissue of the neck, drained from a wide lateral incision. This method of treatment should be recommended for combined lesions of the spine, complicated by infection from the wounded esophagus and pharynx. Gastrostomy is not necessary, as was previously insisted on “with the expectation of producing plastic surgery in the future.” It is more advisable to introduce a probe on which the esophagus should form and which should protect the neck and, in particular, the wounded spine from infection.
Nerve damage from neck injuries
Damage to the cervical spine is often accompanied by injury to the spinal cord and its roots.
Blunt subcutaneous injuries of the brachial plexus in the neck in peacetime are the result of street and industrial trauma. During war, the brachial plexus is stretched during transport, when struck by blunt weapons, sticks, or falling logs. More often in the neck, the brachial plexus is affected as a result of its overstretching.
Among the injuries to individual nerves in the neck, the most important are the damage to the vagus nerve and its recurrent branch, the nerve of the thoracoabdominal septum, the sympatheticus, the hypoglossal and the accessory.
The vagus nerve is relatively often injured when removing malignant tumors in the neck, especially when removing lymph nodes affected by metastatic tumors. The nerve can also get into the ligature when ligating the carotid artery, and more often the jugular vein (see Tumors of the neck).
The recurrent branch of the vagus nerve is often affected when the inferior thyroid artery is ligated or when a goiter is removed.
If an injury to the vagus nerve in the neck occurs below the origin of the superior laryngeal nerve, then the injury will respond to the functions of the corresponding recurrent nerve. A number of laryngeal muscles, including the glottis dilators, will be paralyzed, and the corresponding vocal fold will become immobile (cadaveric position). In this case, the voice becomes rough, hoarse, or the patient completely loses his voice.
Flow. With unilateral transection of the vagus nerve and its resection, there are usually no dangerous phenomena from the lungs, heart, digestive tract and the whole body.
When the vagus nerve is captured in a ligature, severe symptoms of vagal irritation, respiratory arrest, and disruption of the heart occur. These phenomena are caused by both reflex excitation of the arresting centers of the heart and breathing in the medulla oblongata, and excitation of the centrifugal cardiac branches. If the ligature from the nerve is not removed, death may occur.
With bilateral damage to the vagus nerves and the recurrent branch, death occurs within 2 days from paralysis of the glottis dilators and disruption of the heart and lungs. Oncoming pneumonia is associated with the ingestion of infected saliva, expansion of the lungs and an increase in the frequency of respiratory movements; the pulse is sharply increased.
Treatment. If symptoms characteristic of vagal irritation are observed, an attempt should be made to remove the ligature. If this is not possible, it is necessary to separate and separate the vagus nerve from the vessels ligated with it and separately cross the nerve above the ligature. This can save the patient. In rare cases, resection of the ligated nerve may be performed.
The hypoglossal nerve is injured during injuries to the submandibular region, mainly in suicides. As a result of injury to this nerve, partial paralysis of the tongue occurs; when protruding, the latter deviates to the side. With bilateral wounds, complete paralysis of the tongue is observed.
Treatment should consist of suturing the hypoglossal nerve. G. A. Richter successfully restored the integrity of the wounded man with a sharp knife. The literature describes 6 cases of injury to this nerve (3 stabbed and 3 gunshot); In none of these cases was a suture used. There was a case where incomplete transection of the hypoglossal nerve was observed due to a stab wound with a knife. There was a spontaneous improvement.
Unilateral injuries to the phrenic nerve often go unnoticed, since the innervation of the diaphragm is partially replaced by branches of the intercostal nerves. A. S. Lurie points out that during neck operations for a brachial plexus injury, he was diagnosed with a break in the phrenic nerve 3 times. He also notes that in one patient, due to collateral innervation (lower intercostal), the movements of the diaphragm on the side of the injury were not disturbed radiologically.
Thus, it should be said that the therapeutic use of frenicotomy does not always result in permanent paralysis of the diaphragm.
In animal experiments, bilateral transection of the phrenic nerves in the neck causes death from respiratory paralysis. Irritation of the phrenic nerve is characterized by a continuous cough with wheezing due to irregular contractions of the diaphragm.
Injuries to the sympathetic nerve are observed more often with gunshot injuries, localized either at the top of the neck, behind the angle of the jaw, or at the bottom, a few centimeters above the collarbone.
The most constant sign of injury to the sympathetic nerve is a narrowing of the pupil and palpebral fissure (Horner's syndrome), as well as a number of trophic and vasomotor disorders: redness of the corresponding half of the face, conjunctivitis, lacrimation, myopia.
Sometimes exophthalmos is observed - with an isolated wound of the nerve with a piercing weapon above its upper node.
When the sympathetic nerve in the neck is irritated, the pupil dilates, the heartbeat accelerates, and the same phenomena occur as with paralysis of the vagus nerve.
Paralysis of the accessory nerve can occur when it is crossed either before entering the sternocleidomastoid muscle or after it exits into the lateral triangle of the neck. Complete paralysis of these muscles does not occur due to collateral innervation from the cervical plexus.
If the accessory nerve is paralyzed, paralytic torticollis may occur, and if the nerve is irritated, spastic torticollis may occur.
Damage to the thoracic duct due to neck injury
Damage to the thoracic duct in the neck is relatively rare and occurs with stab, knife, or gunshot wounds. Much more often, damage to the thoracic duct occurs during operations for enucleation of tuberculous lymph nodes, during extirpation of cancer metastases, during oncological operations, and operations for aneurysms. However, descriptions of injuries to the thoracic duct on the right are provided.
The diagnosis of injury to the thoracic duct during surgery is facilitated if, 2-4 hours before a major surgical intervention on the neck, the patient is given food with easily digestible fats - milk, cream, bread and butter. If an accidental injury to the thoracic duct occurs, it is immediately noticed during surgery by the release of a whitish, milk-like fluid. Sometimes the damage is determined only a few days after the operation when the dressings are changed by the presence of lymph leakage - lymphorrhea. Sometimes, the morning after the operation, a bandage is found heavily soaked with light liquid - this makes one suspect a wound to the thoracic duct.
Flow. The consequences of lymphorrhea are not very dangerous, especially if one of the branches of the ducts flowing into the vein is injured. Sometimes the loss of fluid from the wounded duct can be quite massive. G. A. Richter reports on a patient in whom, after removal of cancerous lymph nodes in the supraclavicular region, lymphorrhea was discovered only during the first dressing; lymphorrhea continued for 2 weeks, despite tight tamponade. In such cases, large losses of lymph lead to cachexia and threaten life.
Treatment. If a wound to the thoracic duct is discovered during surgery, then ligation of both the central and peripheral ends of the cervical part of the duct is performed. This ligature is well tolerated by patients due to the existence of several junctions of the duct into the subclavian vein and other communications between the thoracic duct and the venous network.
With good results, suturing the duct is sometimes used for lateral wounds. N.I. Makhov, using atraumatic needles, sutured the duct with nylon threads, placing a piece of muscle on them.
Recently, there have been reports of successful suturing of the end of the duct into an adjacent vein.
Surgeons describe sewing a duct into the vertebral vein this way. It is easily accessible in a triangle bounded by the sympathetic nerve medially, the thyrocervical trunk and inferior thyroid artery laterally, and the subclavian artery inferiorly. The risk of air embolism when transplanting into the vertebral vein is much less than into the subclavian vein. The vertebral vein is ligated as proximally as possible, and the assistant presses it with a tuff distally. A 2-3 mm incision is made on the anterior surface of the vein in the space between the tuffer and the ligature.
The thoracic duct is pulled with two very thin vascular sutures to a transverse incision on the anterior surface of the vein.
When applying a suture, an incision is made on the duct from the outside inward, and on the vein - from the intimal side with an incision on its surface. The duct seems to be slightly drawn into the vein by the sutures. The suture area is covered with a section of the prevertebral fascia with 1-2 sutures. A small tampon is inserted into the corner of the wound.
The physiological suction of lymph by the central end of the ligated vein saves from lymphorrhea to a greater extent than the sealing of the suture of the anastomosed vessels.
If it is impossible to perform one of the mentioned restorative operations, a dense tamponade is performed, which also manages to achieve the cessation of lymphorrhea by restoring the main lymph flow through one of the collateral ducts. However, the possibility of septic complications in these cases is greater.
Enhanced nutrition is necessary for patients with neck wounds due to their loss of a significant amount of lymph containing a large amount of nutrients.
The article was prepared and edited by: surgeonThere are neck injuries closed And open .
Closed (stupid) neck injury can be caused by a blow to the front of the neck with a hard object, and also occurs during hanging and strangulation.
Clinical picture. Neck trauma is accompanied by more or less pronounced hemorrhages due to vascular damage. Depending on the place of application of force and its power, one should always keep in mind the possibility of damage to the organs of the neck, and in particular the cartilage of the larynx.
In case of damage to the lateral sections of the neck, and in particular the area of the sternocleidomastoid muscle, it is necessary to take into account possible damage to the branches of the cervical and brachial plexus, which in the middle third of this muscle extend along the posterior edge to its anterior surface. Damage entails motor and sensory paralysis (=complete absence of voluntary movements) of the corresponding parts of the neck and upper limb.
When a muscle is damaged, victims complain of pain in the area of injury. The head is tilted towards the injury, the face is slightly turned. On examination, swelling is detected. Large hemorrhages deep in the neck, near the esophagus and trachea can fester.
Treatment conservative. It comes down to creating rest, applying a bandage, symptomatic therapy, and physical therapy.
Neck wounds in peacetime they are rare. Neck injuries are described and are severe due to the location of large vessels, trachea, and esophagus in the area of damage.
There are cut, stab and gunshot wounds to the neck. Incised wounds are usually inflicted during a suicide attempt. They have a transverse direction and are located below the hyoid bone. The peculiarity of these wounds is damage to the veins and significant bleeding, as well as injury to the tracheal wall.
In case of neck injuries, air embolism is possible along with bleeding. Air is sucked in due to negative pressure in the chest through a gaping wound in the venous wall. The veins in the neck do not collapse, as they are fused with dense fascia. Embolism is manifested by a whistling sound when air is sucked into the wound, and pale skin. There is tamponade of the right side of the heart with air, followed by asystole and respiratory arrest.
They are classified according to the type of wounding weapon.
You can practically identify the wounds superficial And deep . In case of superficial damage, the skin, superficial fascia, superficial large blood vessels, nerves, and thoracic duct are damaged.
Of the large arteries of the neck, the most frequently injured a. Carotiscommunis, =carotid artery(isolated or together with v. Jugularis interna, = internal jugular vein And n. Vagus = vagus nerve).
While not rare, injuries to the common carotid artery are, at the same time, rarely the subject of surgical intervention due to the fact that they quickly lead to death. With incised wounds, usually inflicted for the purpose of suicide, the common carotid arteries usually escape the cut, although the wound can penetrate deep into the spine. This ability to escape is explained by the easy mobility of the arteries in loose tissue (due to elasticity and their displacement in depth when the head is thrown back at the time of injury). At the same time, the larynx and trachea protruding forward take the blow. When a small artery is injured, the tissue surrounding the site of the vessel plays the role of a tampon, preventing blood from leaking out. The shedding of blood around the vessel enhances this tamponade, compressing the vessel. A drop in blood pressure due to blood loss, in turn, is a moment conducive to stopping bleeding. Hematomas can compress the airways and then fester.
Diagnosis Injuries to the common carotid artery can be diagnosed easily in the presence of bleeding and difficult to stop.
Urgent Care for neck injuries:
€ For pain relief, administer intramuscularly. 1 ml of 2% promedol solution;
€ Stop bleeding depending on its type: for venous bleeding, apply a tight bandage; for arterial bleeding, apply a tourniquet or use other methods to temporarily stop bleeding;
€ With the development of hemorrhagic shock, infusion therapy with blood replacement solutions is necessary;
€ Hospitalize the victim in a medical and preventive institution.
Treatment operational. It consists of applying a vascular suture or ligating the artery above or the site of injury along with the jugular vein. Sympathetic nodes are blocked.
There may be injuries a. Subclavia (= Subclavian artery ) , which leads to malnutrition of the limb and a. Vertebralis (= vertebral artery ) . In these cases, treatment is surgical.
Features of stopping bleeding in neck wounds and traumatic amputations of limbs
1. Neck injuries, accompanied by external arterial bleeding, usually lead to death immediately after injury. The need to stop bleeding occurs only in extremely rare cases. To do this, it is recommended that the contents of the dressing bag, freed from the membrane, be pressed against the bleeding wound.
The hand opposite the side of the wound is placed on the victim’s head so that the shoulder is in contact with the side surface of the head and neck, and the forearm lies on the vault of the skull.
Thus, the shoulder of the wounded person plays the role of a splint, protecting the large vessels of the neck of the uninjured side from compression. A tourniquet is placed around the wounded person's neck and shoulder.
After external bleeding has been stopped by one of the necessary methods, it is advisable, if possible, to free the wounded person from wet clothes and cover him warmly.
All wounded people with blood loss are concerned about thirst, so they should be given water to drink without restrictions, and if possible, warm tea.
Bleeding from minor neck wounds is stopped by applying a bandage.
The bandage is applied to the neck using a circular bandage. To prevent it from sliding down, circular rounds on the neck are combined with rounds of a cruciform bandage on the head.
2. Emergency care for traumatic amputations of limbs
First of all, it is necessary to stop bleeding from the stump of a limb or hand by applying a pressure bandage and inflatable cuffs (a tourniquet is applied as a last resort). Instead of a standard hemostatic tourniquet, use a belt, tie, tightly folded scarf, or scarf. Keep the injured limb in an elevated position. it is necessary to put the victim to bed, give him an anesthetic, and give him strong tea. Cover the wounded surface with a clean or sterile cloth.
Technique for applying a returning bandage.
Bandaging begins with securing circular tours in the upper third of the affected limb segment. Then hold the bandage with the first finger of the left hand and make a bend on the front surface of the stump. The bandage moves in the longitudinal direction through the end part of the stump to the rear surface. Each longitudinal stroke of the bandage is secured in a circular motion. The bandage is bent on the back surface of the stump closer to the end part and the bandage is returned to the front surface. Each returning round is fixed with spiral moves of the bandage from the end part of the stump.
If the stump has a pronounced cone-shaped shape, then the bandage is stronger when the second returning stroke of the bandage runs perpendicular to the first and intersects at the end of the stump with the first returning tour at a right angle. The third returning move should be carried out in the interval between the first and second.
Returning strokes of the bandage are repeated until the stump is securely bandaged.
Returning bandage on the stump of the forearm. The bandage begins in circular motions in the lower third of the shoulder to prevent the bandage from slipping. Then the bandage is passed to the stump of the forearm and a returning bandage is applied. Bandaging is completed with circular rounds in the lower third of the shoulder.
Returning bandage on the stump of the shoulder. The bandage begins in circular motions in the upper third of the shoulder stump. Then a returning bandage is applied, which is strengthened with the moves of a spica bandage on the shoulder joint before completion. The bandage is completed with circular rounds in the upper third of the shoulder.
Returning bandage on the stump of the leg. The bandage begins in circular motions in the upper third of the lower leg. Then a returning bandage is applied, which is strengthened with eight-shaped moves of the bandage on the knee joint. The bandage is completed with circular rounds in the upper third of the lower leg.
Returning bandage on the thigh stump. The bandage begins in circular motions in the upper third of the thigh. Then a returning bandage is applied, which is strengthened with the moves of a spica bandage on the hip joint. The bandage is completed with circular tours in the pelvic area.
Scarf bandage on the thigh stump. The middle of the scarf is placed on the end of the stump, the top is wrapped on the front surface of the stump, and the base and ends of the scarf are wrapped on the back surface. The ends of the scarf are wrapped around the upper third of the thigh, forming a bandage, tied on the front surface and the top is fixed to the knot.
Similarly, bandages are applied to the stumps of the shoulder, forearm and lower leg.
Of the closed neck injuries, the most important are those that are accompanied by contusion, compression or rupture of the spinal cord due to fractures and dislocations of the cervical vertebrae. A typical example is the so-called diver's fracture (see Spine). Compression of the trachea and its deformation due to cartilage fractures are dangerous, threatening obstructive asphyxia (see). There are closed fractures of the hyoid bone, which are usually not dangerous in themselves, but can dramatically impair swallowing (see). Injury to the thyroid cartilage, even a minor bruise, can sometimes cause instant death, reflex cardiac arrest.
Open neck injuries (in peacetime, more often of a stab-and-cut nature, in wartime - gunshot injuries) are divided into penetrating (with disruption of the integrity of the organs of the neck - trachea, esophagus, spine, deep vessels, etc.) and non-penetrating. The latter pose a danger mainly when the external jugular vein is injured (possibility of air embolism).
The severity of penetrating injuries depends on which organ is damaged. Wounds of large vessels (especially the carotid arteries) threaten fatal bleeding (see), the formation of a bursting hematoma, which can compress the trachea and vagus nerve; at best, a traumatic neck aneurysm forms.
Injuries to the trachea often cause asphyxia; wounds of the esophagus lead to serious infectious complications. Injuries to one or another organ are rarely isolated, and their combined nature further increases the severity of penetrating neck wounds.
With a closed injury, the main goals of treatment are to combat asphyxia (if necessary, urgent tracheotomy), decompress the compressed spinal cord, and combat shock. For open injuries; perform primary surgical treatment of the wound according to general rules (see Wounds, wounds), and in the case of a penetrating wound, also restore the integrity of the damaged organ. In addition, there may be a need for tracheotomy, gastrostomy (to temporarily disconnect the affected esophagus), laminectomy (to decompress the spinal cord, remove a foreign body from the spinal canal).
Recognizing injuries to large vessels on the neck in the absence of external bleeding is more difficult than on the extremities. Changes in the pulse of the temporal and mandibular arteries can only occur when the common or external carotid artery is injured, and not always. Murmurs on the vessels are a more constant sign, but are characteristic mainly of lateral and parietal wounds of the artery (S. A. Rusanov); with a complete break there may be no noise. In addition, they can also occur over an intact line, with slight compression from the outside (for example, a hematoma caused by injury to small vessels). Therefore, the most convincing symptom is the formation of a significant pulsating swelling on the neck, usually on the side. At the slightest suspicion of injury to any carotid arteries, even in the absence of bleeding, the vascular bundle of the neck should be immediately inspected, exposing it with a typical incision along the anterior edge of the sternocleidomastial muscle. Such a separate incision is not needed only if the existing wound is located before the same projection, so that convenient access can be achieved through the wound canal by cutting or excision. Violation of this rule (approaching vessels with disadvantageous access) has more than once had the most severe consequences . For injuries of the common or internal carotid arteries, the method of choice is the application of a vascular suture (see). Ligation of these vessels can severely disrupt the blood supply to the brain and should be used only if it is impossible to apply a suture; ligation of both ends of the damaged artery is mandatory - in the neck, bleeding from the unligated peripheral end of the vessel is almost inevitable. Ligation of the external carotid artery is less dangerous. If the jugular veins are damaged during surgery, all precautions against air embolism must be strictly observed (see). In each case of neck injury, it is necessary to check the pulse in the vessels of the upper extremities (damage to another artery is possible). See also Ligation of venous vessels.
Neck injuries There are closed and open ones, which pose a great danger to the patient’s life, as they can be complicated by fractures of the cervical vertebrae or damage to the larynx, trachea, pharynx and esophagus. Gunshot wounds to the neck are rare in peacetime. More often, cut and puncture wounds are observed (see), which require urgent surgical treatment, dissection of the wound channel, stopping bleeding, removal of non-viable tissue, foreign bodies, hematomas and according to indications (see).
The integrity of the wall of an artery or vein can be compromised by closed or open injury. This leads to internal or external hemorrhage and weakened tissue nutrition (ischemia). With intense blood loss, vascular injuries are life-threatening. Treatment of such injuries requires urgent surgery.
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Types of vascular injuries
Internal bleeding, internal organs damaged Depending on whether there are external signs of vascular injury, they are divided into open and closed. The former may be accompanied by a tear or complete dissection of the vascular wall.
Closed injuries are not accompanied by external bleeding, but they lead to thrombosis, intense internal hemorrhage, tissue ischemia, and aneurysm of the wall of a vein or artery.
The danger to life increases if the main vessel is damaged; it is lower if secondary blood pathways are injured. Depending on the type of injured vessel, there are arterial, venous, capillary and mixed pathologies. Blood flow pathways in the arms, legs and neck, head and torso may be affected. Internal bleeding occurs when the organs of the chest or abdominal cavity are damaged. In the case of polytrauma, all these types are combined with each other. 
Based on the nature of vessel ruptures, the following are distinguished:
- full,
- partial,
- through,
- tangentially,
- fenestrating (for puncture, wound by shrapnel).
Clinical signs of injury
The danger of vascular injuries depends on the intensity and type of injury received.
Open
Open wound Most often they manifest themselves in the form of external bleeding, but the vascular defect can be blocked by a thrombus or neighboring tissues, so in the presence of an open wound, sometimes there is no noticeable blood loss.
Injuries are also characterized by the passage of blood into soft tissues with the formation of a hematoma. Significant injuries lead to a drop in hemodynamics and the development of a state of shock. The most severe consequences are for arterial bleeding from large vessels.
Vascular injuries with open injuries come in three degrees of severity:
- Only the outer shell is damaged, the middle and inner layers are not affected.
- Through defect of the vascular wall.
- Full .
Closed
With open injuries, the direction of injury goes from the outside to the inside, and with closed injuries it is the opposite, so the most severe cases are accompanied by complete destruction of the inner layer - the intima of the vessel. With minor injuries, cracks form in it. This is typical for impacts with blunt objects. There is no external bleeding, but an intravascular blood clot forms, leading to ischemia.
Formation of a blood clot due to a bruised vessel The second degree of severity of closed vascular injuries occurs with a circular rupture of the intima and partially the middle layer. For example, in car accidents, a sharp impact leads to the formation of an aneurysmal sac in the area of the aortic isthmus. Severe injuries (third degree) are accompanied by extensive hemorrhages that compress the surrounding tissues. One option may be overextension with rupture due to a dislocated joint or a displaced fracture.
Symptoms of closed vascular injury:
Arteries
If a vessel from the arterial network is damaged, then there are the following characteristic signs:
- scarlet stream of blood;
- bleeding or rapidly growing hematoma with pulsation;
- Below the injury there is no pulse in the arteries;
- pale skin, then cyanotic color;
- numbness;
- pain that does not decrease after fixing the limb does not increase when palpated;
- the muscles become hard (rigidity), initially active movements are difficult, and later passive movements are also difficult (contracture).
Ven
A wound to a venous vessel is manifested by a dark stream of blood, the limb swells, the peripheral veins overflow and swell, the blood stream is smooth. Formed hematomas are often small in size and do not pulsate. Unlike arterial bleeding, there are no signs of ischemia - there is a pulse in the artery, the skin is of normal color and temperature, movements in the limbs are possible (in the absence of a fracture or dislocation).
Vessels of the head and neck
Such injuries carry an increased risk to life. This is due to the following features:
- The respiratory tract and nerve plexuses are located close together, so respiratory arrest and reflex cessation of the heartbeat are possible;
- there is a threat of cessation of nutrition to brain tissue due to ischemia, or with the development of;
- abundant blood supply leads to large blood loss.
Brain contusion with damage to blood vessels When an artery ruptures, there is severe bleeding or a hematoma forms with pulsation on the side of the neck. It quickly spreads to the area above the collarbone, puts pressure on the esophagus, and a breakthrough into the pleural cavity is possible. There is often damage (isolated or combined with arterial damage) to the vein. In this case, the accumulation of blood may not be noticeable; when palpating the neck, slight pulsation and swelling are noted.
Closed injuries are no less dangerous. Even light blows or manual therapy can cause dissection of the artery walls.
Severe pain occurs, disturbances in the blood supply to the brain with weakness in the limbs, slurred speech, facial asymmetry, and unsteady gait, which makes it possible to suspect a stroke.
Limbs
Signs of vessel rupture depend on its diameter and depth of injury. Large arterial and venous trunks pass through the limbs. Gushing bleeding from the femoral and brachial arteries is possible; due to the high speed, clots do not have time to form in them. In such cases, patients require emergency care to prevent major blood loss.
Closed fracture with vein damage Blood flows out of the vein slowly, so most often blood clots form, but they can be washed away by the movement of blood. Venous bleeding is less intense, but you can’t always count on stopping it on your own. The most favorable option for vascular damage is capillary. In this case, the blood is similar to arterial blood, but the signs are only superficial, there is no ischemia.
If the blood clotting activity is normal, then such bleeding will stop when a bandage is applied.
Diagnostics
Most often, the results of a doctor’s examination are sufficient to detect a vascular injury. Angiography, ultrasound, CT and MRI are used to assess the consequences or choose surgical treatment tactics.
The diagnosis is made based on the following signs:
First aid
The amount of assistance at the first stage depends on the degree and type of damage:
- bruise– apply ice, first placing a cloth over the injury site;
- rupture of a capillary or small vein– a pressure bandage made of a bandage or any available fabric (belt, scarf, handkerchief, towel);
- arterial- pressing with a finger or fist, then apply a tourniquet to clothing or fabric in several layers, and under it a note with the time of application.
The use of a tourniquet is advisable only on the thigh or shoulder, since the vessels of the lower leg and forearm are located deep and cannot be compressed from the outside. The maximum time for which a limb can be clamped is 60 minutes for adults and up to 20 minutes for children.
The main assistance to the victim is immediate transportation to a medical facility, so you need to call an ambulance as soon as possible. Before doctors arrive, you need to ensure the immobility of the injured limb. It must not be lifted, warmed or cooled.
Wounds to the neck are dangerous not only due to blood loss, but also due to the entry of air bubbles with subsequent embolism of cerebral vessels. Therefore, as soon as possible, you need to apply a rolled bandage or something similar to the bleeding site. To apply a bandage, the victim’s arm is raised up, and the turns of the bandage pass through it. This provides nutrition to the brain through the second, paired carotid artery.
Watch a video about first aid for injuries:
Surgery
After admission to the hospital, the patient first receives infusion therapy to restore circulating blood volume. For this purpose, droppers with isotonic solutions of sodium chloride, glucose, Albumin, Reopoliglucin, Voluven, Refortan are used. Indicated in a volume of about 2 liters and 4 liters of solutions for damage to a large vessel.
Reconstructive surgery begins at a pressure of at least 100 mmHg. Art. and a pulse of about 100 beats per minute, but if the bleeding continues and threatens life, then the patient will be operated on immediately after hospitalization. Vascular operations are justified if there are signs of tissue viability - deep sensitivity is preserved, there is no muscle contracture. If these symptoms are present, the question of amputation is raised.
The integrity of the artery is restored in the following ways:
- side or circular seam;
- plastic surgery using your own vein or graft;
- connection of ends with a defect of no more than 2 cm.
In case of injury, veins are used, and if the damage is significant, then the thigh vein is isolated and used for plastic reconstruction.
Prognosis for the patient
Factors that have an adverse effect on vascular injury:
- open damage;
- rupture of a large diameter artery;
- combined injuries (bones, soft tissues, nerve trunks are damaged, vital organs are affected);
- large blood loss;
- localization on the neck;
- More than 6 hours passed from the moment of injury to the operation.
