(1)Hemostasis: open neck injury often injures the large blood vessels in the neck, and bleeding is the most important cause of death in neck injury
①Shiatsu hemostasis: used for emergency hemostasis of the common carotid artery. With the thumb at the anterior edge of the sternocleidomastoid muscle, flush with the plane of the cricoid cartilage, to the 6th cervical vertebrae transverse process of pressure, can close the common carotid artery. The finger can also be inserted into the wound to compress the bleeding vessel.
②Arm and neck pressure bandage hemostasis method: used for unilateral bleeding of small blood vessels. The healthy side of the upper limb is lifted up and attached to the side of the head. To raise the arm as a pillar to raise the arm and neck together with the pressure bandage (Figure 4) This method does not compress the airway, there is a compression hemostasis. Pressure bandage hemostasis can not be alone bandage around the neck pressure bandage, so as not to compress the airway, resulting in respiratory distress. Small blood vessel bleeding, can also be used to fill the hemostasis method.
③Pressure bandage: when the large vein in the neck is broken, pressure bandage should be applied immediately. Because the large neck vein and fascia are closely linked, after the rupture of the vein, the rupture can not be closed but open. When inhaling the negative pressure in the chest cavity, air can be sucked into the rupture of the vein, and air embolism occurs. Therefore, pressure bandage should be applied immediately after the injury, and the patient's respiration should be closely observed.
Note: When the initial treatment, avoid using hemostatic forceps to blindly clamp to stop bleeding. Especially when the common carotid and internal carotid arteries are bleeding, blind clamping will lead to insufficient blood supply to the ipsilateral brain. In addition, when the bleeding point is not clear, do not blindly clamp hemostasis because it is easy to damage the important blood vessels in the neck, nerves and other adverse consequences.
④Surgical exploration: if the initial treatment is ineffective, tracheal intubation and cervical incision should be performed immediately to stop bleeding. Some authors believe that the management of large vessel injuries in the neck can be treated separately according to the 3 zones of the neck.
A. Hemodynamically unstable people, the condition is critical, no matter what area of the injury, need immediate surgical exploration to stop bleeding
B. Hemodynamically stable people with selective treatment: Ⅰ adjacent to the thoracic cavity, Ⅲ adjacent to the base of the skull, the anatomical complexity of the treatment is more difficult, and more auxiliary examination (angiography, endoscopy, etc.) to determine the site and nature of the injury, to determine the surgical approach and measures. In the past, immediate surgical exploration of the blood vessels was often adopted for zone II injuries, and due to the high negative rate, selective treatment has also been advocated in recent years, with better results.
(2) Anti-shock: emergency hemostasis is the most important prerequisite for anti-shock.
1) Although the bleeding has been stopped, but due to excessive blood loss, the emergence or imminent emergence of shock should be immediately measured blood pressure. Systolic blood pressure lower than 12.0kPa (90mmHg), pulse higher than 100 beats/min should be considered the existence of shock. Bilateral intravenous fluids should be given rapidly. Administration of 2,000 ml of lactated Ringer's solution generally restores blood volume in adults who have lost 10% to 20% of their blood volume. For severe reduction of blood volume, severe shock or infantile shock and pre-existing hepatic impairment, sodium bicarbonate Ringer's solution or a mixture of sodium bicarbonate and isotonic saline, or glucose plus sodium bicarbonate solution can be used instead.
②Severe hypovolemia or moderate hypovolemia, and there is continued bleeding, must be added to the transfusion of whole blood, so that the hemoglobin reaches more than 100g / L, in order to maintain normal blood volume and the physiological function of vital organs. Then continue to enter the balanced electrolyte solution.
③Arterial blood transfusion can rapidly restore blood pressure, and is indeed an effective method for those with massive hemorrhagic shock.
④Others: such as giving oxygen, analgesia, sedation, warmth and head-down position.
(3) Relieve respiratory distress: respiration must be closely observed in open neck injury. Immediately take effective patency measures in case of respiratory distress.
①Excluding foreign bodies in the airway: use suction or syringe to draw blood and secretion in the mouth, laryngopharynx or laryngotracheal rupture. If a foreign body is found, it should be removed immediately.
②Prevent tongue drop: tongue drop, tongue forceps should be used to pull the tongue out of the mouth or support the mandible, or inserted into the ventilation tube to relieve breathing difficulties.
③ tracheal intubation and broken suture: laryngeal tracheal rupture, can be temporarily inserted through the rupture tracheal tube, or suitable plastic and rubber tubes, such as laryngeal tracheal disconnection should be immediately downward recession of the trachea upward pull up and temporary suture fixation, in the mouth of the break temporarily placed into an appropriate tube, to maintain a smooth airway
④ low tracheotomy: to be transported to the conditions of the patient's medical institutions, should be carried out immediately. Low tracheotomy should be performed immediately after the patient arrives at a qualified medical institution to avoid long-term placement of a tube in the wound, resulting in scarring stenosis of the laryngotrachea.
⑤Cricothyrotomy: In emergency situations, cricothyrotomy can also be performed to insert a tracheal tube or plastic rubber tube to temporarily relieve the patient's respiratory distress. When the situation is stabilized, then low tracheotomy.
In addition, Mosher emergency tube, anesthesia laryngeal intubation or tracheoscopy, if can be inserted quickly, can be effective in relieving respiratory distress, but some of the open neck injuries laryngeal mucosa or neck soft tissues are highly swollen, or there is a large hematoma of the neck, can not tilt the head back to make it difficult to intubate, then we must immediately perform an emergency tracheotomy or cricothyrotomy.
If dyspnea persists after the airway is cleared, the possibility of pneumothorax or hemothorax should be considered, and chest examination and treatment should be performed immediately.
6. Emergency laryngeal exploration: open neck injury affecting the larynx, emergency laryngeal exploration and low tracheotomy should be performed as appropriate
A. Indications for laryngeal exploration: airway obstruction and progressive aggravation of subcutaneous emphysema of the neck; laryngeal laryngeal cavity can be seen in the laryngeal cartilage pieces of large pieces of crushed and torn laryngeal cartilage; laryngeal cartilage collapsed or fractured to cause severe deformation of the larynx; bilateral laryngeal recurrent nerve injury.
B. The role of tracheotomy: to relieve respiratory distress, to create the opportunity to rescue and further diagnosis and treatment to avoid death; if a sudden asphyxia (such as blood or blood clots into the respiratory tract), easy to carry out emergency treatment to reduce the ineffective lumen of the upper respiratory tract; easy to respiratory secretions through the short-circuit (tracheal cannula) unimpeded coughing up, or suctioning through the tracheal cannula to reduce the chances of neck infections and emphysema occurred ;Convenient and effective oxygenation; reduce the pressure in the airway when coughing, reduce the suture tension of the wound, promote wound healing and prevent rupture; promote the rest of the injured larynx and the recovery of function.
(4) Head braking: if there is cervical pain, pressure pain, hematoma or deformity should think of the possibility of cervical spine injury (fracture and displacement). If the patient is paraplegic, it means that the spinal cord is damaged. First aid should not be stretched and twisted head and neck; handling with both hands to support the shoulders and head; lying down should be removed from the pillow lying down or prone, the head should be placed on both sides of the sandbags, etc.
Just avoid tracheotomy anesthesia laryngeal intubation and endoscopic surgery. If necessary, it should be performed without tilting the head.
(5) the treatment of coma: coma suggests a combination of craniocerebral injury or excessive blood loss should be immediately emergency, and neurosurgery and internal medicine doctors to help deal with.
(6)Treatment of foreign body: In first aid, foreign body can not be removed from the wound, unless the foreign body causes respiratory obstruction and is easy to remove, but also need to pay attention to remove the foreign body to see if there will be another hemorrhage, if there is a possibility of hemorrhage, can be left until the surgical treatment of the removal of foreign body.
(7) First aid for combined injuries: head, face, chest, abdomen, and limb injuries should be given first aid together, and the assistance of a surgeon should be requested.
First aid places have limited rescue equipment, the patient after initial treatment should be quickly transferred to a qualified medical institutions, in order to better for further treatment. In order to avoid blood, saliva and vomit inhalation of the respiratory tract, resulting in respiratory difficulties, in the transportation, the head should be turned to the affected side, can also be taken to prone position if the patient is comatose or lower respiratory secretion is more, should be carried out tracheotomy before referral, but cervical vertebrae fracture, tracheotomy to be particularly cautious
2. general surgical treatment
(1) debridement and suturing: did not injure the important structures of the neck, should be carried out debridement and suturing. The patient should be treated with a debridement suture.
①Cleansing and hemostasis:Stuff the wound with sterile gauze and wash the skin around the wound with sterile soapy water and saline (Figure 6A). After changing gloves and sterile sheets, inject l% procaine solution through the skin outside the wound margin for infiltration anesthesia, wash the wound with sterile saline and examine the wound carefully. Tissues that have lost viability may be excised (Fig. 6B). However, resection of important structural tissues should be done with caution. Carefully search for bleeding points, especially potential bleeding points, to be ligated. This is to prevent active bleeding or even hemorrhage from being induced again after the shock is corrected, due to the recovery of blood pressure, or postoperative change of medication, coughing, or infection of blood clots.
②Remove the foreign body: In principle, the foreign body in the wound should be removed in a timely manner, which is the key to reducing complications and mortality. The retention of foreign objects not only increases the chance of wound infection but also further damages the important structures of the neck. Removal of the foreign body needs to be combined with the preoperative examination and intraoperative observation, its location, size and shape, etc., to carry out in-depth examination and research, and develop a safe method and steps for removal before removal.
③Wound closure:
A. Wounds that are not seriously contaminated can be closed by suturing after careful exploration and repair: wash the wound adequately, pull the broken ends of the muscles together, and suture them; suture subcutaneous tissues and the skin at the low point of the suture wound into a strip of rubber membrane or cigarette-type drainage strips; and postoperative antibiotics should be applied in conjunction with the suture.
B. Wounds with obvious infection must be left open for dressing changes: remove purulent secretions from the wound, clean the wound and cover it with a Vaseline gauze block and dressing to end the operation. Postoperatively, change the dressing daily with furacilin liquid or antibiotics, so that the wound granulation from the bottom of the gradual outward growth. When the wound grows flat, skin grafting or leave it epithelialized, or give two-stage suture.
(2)Treatment of injury to important structures in the neck: Injury to important structures in the neck such as large blood vessels, important nerves, laryngotracheal tube and pharyngo-esophageal tube often results in dangerous complications and increases the rate of death, so it must be treated appropriately and in a timely manner.
①Surgical treatment of laryngotracheal injury: after the diagnosis is clear and early under general anesthesia (laryngotracheal intubation anesthesia is used if necessary) for debridement and suturing.
A. Cartilage suture: laryngotracheal cuts are mostly transverse incisions, absorbable sutures (No. 4-0 chromium gut) or Dexon sutures can be used to suture the outer cartilaginous membrane of the laryngotracheal incision, such as the cartilage is only one transverse cut, and there is no fragmented cartilage, then the outer cartilaginous membrane can be intermittently sutured, and the cartilage and mucous membranes can be aligned to the reset, and well fixed. If the cartilage incision is large, only sewing the cartilage membrane can not be well aligned to fix the cut cartilage can be used very fine stainless steel wire (No. 28), the cartilage will be drilled a few small holes, aligned with the suture fixation. If the cartilage is comminuted, the cartilage fragments cannot be taken out casually, and must be well reset, sutured and fixed
B. Placement of a laryngeal dilatation tube: In order to prevent laryngotracheal scarring stenosis, a laryngotracheal dilatation tube should be placed after the reset.
The laryngeal dilatation tube (laryngeal mold) can be made of less irritating silicone rubber tubing. During the operation, it is trimmed into a certain shape according to the need, and sent into the trachea and larynx through the tracheal incision opening, and placed in the appropriate position in the laryngeal tracheal lumen, and then a thin stainless steel wire is tied through the lower end of the laryngeal dilatation tube to the tracheal tube to fix it.
The laryngeal dilatation tube is removed by cutting the wire attached to the tracheal tube and then extracting the tube under direct laryngoscopy with a pair of pliers.
The laryngeal dilator tube can also be surgically placed in the appropriate position within the laryngotracheal lumen, and then the cartilage fragments can be repositioned in good alignment, and the outer cartilaginous membrane can be closed with a No. 4-0 chromium gut or Dexon suture. If the laryngotracheal breach is large and the wall defects are numerous, after placing a laryngeal dilatation tube, the soft tissues can be loosely sutured together somewhat and then covered with adjacent available muscle tissue or thyroid and secured with sutures. Finally suture the broken muscle, subcutaneous tissue and skin placed rubber membrane strip or cigarette-type drainage in the lowest part of the suture wound to be wrapped, end of the operation.
C. Treatment of severely contaminated septic wounds: For severely contaminated septic wounds, after repairing the laryngotracheal rupture, the muscle or thyroid gland can be used to cover the suture rupture and fixed with sutures. The neck wound was left open without suture, and postoperatively, it was changed daily with furacilin solution or sensitive antibiotics for gradual healing.
D. If the epiglottis cartilage is cut off and there is a mucosal connection, the cartilage can be closed with 28-gauge stainless steel wire with l to 2 stitches to reset the cartilage, and the mucosa can be closed with 4-0 chromium enteric thread or Dexon suture intermittently. If the epiglottis cartilage is cut off and there is an enthesis connected to the cartilage, the cartilage and the damaged mucosa can be closed with intermittent suture.
Triangular needles and 28-gauge stainless steel wires are often used to close cartilage fragments. Generally young people and middle-aged people's cartilage is not yet calcified, can use the triangle needle suture. Elderly people's cartilage has been calcified, must use 0.5mm straight drill bit to drill holes and then wear a good wire with pliers. Wait until all the wires are threaded before tying the knot.
E. Treatment of large tracheal defects: large defects can be wrapped in skin or fascia on the surface of the laryngotracheal tube expansion, placed in the defect, the anterior wall of the cricoid cartilage and the anterior wall of the trachea is too much, the use of autologous cartilage or bone with the tip of the square bone piece of grafting to repair. If the trachea is completely cut off and retracted, the upper and lower ends of the trachea should be free and then pulled together for butt-end anastomosis.
F. Surgery for penetrating injury: If the neck is penetrating injury, once the diagnosis of laryngotracheal injury is confirmed, the neck should be incised under local anesthesia or tracheal tube anesthesia as early as possible to find out the injury and repair it. A longitudinal incision can be made in the midline of the neck, or a slightly curved transverse incision can be made through the midpoint of the thyroid cartilage, i.e., the incision is made along the dermatomal line, and the incisional scar is inconspicuous after the operation. Regardless of the incision, the sternocleidomastoid muscle and sternocleidomastoid muscle may not be severed, and the subcutaneous tissues may be pulled to both sides to make the surgical field more spacious. Suturing the laryngotracheal cartilage and placing the laryngeal dilatation tube are very convenient.
The repair of laryngotracheal breach is very important and should be done carefully and securely so that the gas and secretion cannot leak out to prevent complications and heal quickly after surgery
(2) Surgical management of pharyngo-esophageal injuries: putting a nasogastric tube into the laryngeal esophagus before the surgery not only supplies nutrition, but also helps in recognizing and identifying the pharyngo-esophageal breach, and if it is not possible to insert a nasogastric tube before the surgery, it can be inserted in the beginning of the surgery or in the middle of the surgery, so that it will be easy for the laryngotracheal cartilage to be closed. Insertion of a nasogastric tube
A. Initial closure of pharyngo-esophageal breach: It is best to use a fine chrome gut or Dexon suture to make a transverse extra-mucosal suture to avoid postoperative stricture formation. After the extra-mucosal suture, the patient is instructed to make swallowing movements, and if the suture leaks air or saliva during swallowing, a few additional stitches must be added until there is no leakage. Longitudinal sutures can only be used for particularly long longitudinal esophageal ruptures.
B. Suture of the muscular layer of the pharyngo-esophagus: In order to prevent the leakage of pharyngo-esophageal contents into the neck wound, the muscular layer of the pharyngo-esophagus should also be carefully sutured, and the adjacent connective tissues or other muscles or the thyroid gland can also be used to cover the rupture with sutures and fixed sutures in order to enhance the chances of repairing the rupture. If the pharyngo-esophageal injury is prolonged, it should also be sutured and the wound should be drained.
If the pharyngo-esophageal breach is so large that the initial suture cannot be made, the breach can be pulled together properly with a few loose interrupted sutures of fine intestinal thread. If the wound can be healed, it is ideal; if it cannot be healed, it is hoped that the breach will be as small as possible and will be easier to repair in the future. Neck wounds can be left open to allow adequate drainage, which is conducive to wound healing. For infected and septic wounds, the pharyngo-esophageal breach should also be repaired and the neck wound left open. If the pharyngo-esophageal breach is repaired successfully, the neck wound will also heal slowly.
C. Management of esophageal dissection: In cases where the esophagus is completely severed and retracted, the upper and lower esophagus must be separated and anastomosed to the opposite end.
D. Drainage of wound: pharyngo-esophageal injuries are prone to complicate neck and mediastinal infections, which are often due to improper surgical repair or poor drainage of the neck. Therefore, adequate drainage of the neck wound is the key to the success of the repair, otherwise, it will cause serious infection of the neck and mediastinum, and even death If necessary, drainage strips should be placed at both ends of the suture incision, but it should be noted that the drainage strips can not be placed in the pharyngo-esophageal breach repair, so as not to affect the healing of the repair.
(3) Surgical management of thoracic duct injury: when there is leakage of celiac fluid from the neck wound, it suggests that there is a thoracic duct injury, which should be immediately bandaged with pressure.
①Clean up the wound and suture: when clean up the wound and suture, you need to find out the break of celiac leakage or disconnection of the thoracic duct breaks at the distal and proximal ends of the thoracic duct to be ligated with silk thread, which is the most reliable treatment. After ligating the thoracic duct, there will not be any problems, because there are many transportation branches between it and the right lymphatic vessels and there are many lymphatic and venous channels. If it is a jugular penetrating injury, the site of celiac leakage should also be carefully searched for and treated in the same way in the jugular incision and exploration.
If the above treatment of celiac leakage recurrence, need to re-open the neck wound and then ligation to stop the leakage of 15min before the operation, the patient was asked to eat a fat-containing diet or appropriate amount of fat-soluble dyes, the operation can be seen to gush out of the milky white liquid and dyes to help the identification of the thoracic duct rupture site.
②Celiac disease treatment: celiac disease requires thoracocentesis and fluid extraction, if necessary, closed chest drainage, either cervical celiac fistula or celiac disease can occur for a long time and a large amount of celiac disease leakage, the patient is often severely dehydrated and lethargy, it should be actively dealt with, and every day to give a sufficient amount of intravenous fluids to replenish electrolytes, protein and fat. If the patient is able to eat, a high-fat, high-protein diet should be given.
(4) Surgical treatment of thyroid injury: the main problem of thyroid breakage is stubborn bleeding that is difficult to stop, sometimes it can form a large hematoma in the neck, compressing the respiratory tract, causing respiratory distress, and even death should be stopped immediately, and the broken thyroid gland should be resected to be ligated through and through. If both the left and right lobes of the thyroid are broken and bleeding, they can be excised and the thyroid isthmus left in situ, usually without the appearance of hypothyroidism or mucous edema. If the thyroid gland is severely damaged, the boundary is blurred, the bleeding is difficult to stop, and resection of the damaged thyroid gland cannot be carried out, at this time, the external carotid artery can be pressed to reduce the bleeding, and the upper and lower thyroid arteries can be found immediately and ligated in order to stop the bleeding. Although ligation of the upper and lower thyroid arteries on both sides will not lead to thyroid necrosis.
(5) Surgical treatment of salivary gland injury: generally can be sutured if there are obvious ducts visible in the breach, it should be ligated. If the submandibular gland is severely damaged and difficult to repair, or if there is a possibility of salivary fistula after repair, the submandibular gland can be removed. Generally, the salivary fistula can be closed by itself within 3 months, and if it does not heal for a long time, then the fistula resection or repair can be considered. Injury to the common parotid duct is rare, if it has been severed, a small plastic tube should be inserted into the two severed ends of the common parotid duct from the oral cavity, and then anastomosis should be performed. After the connection heals, the small plastic tubes are removed.
(6) Surgical management of pleural roof injury: pleural roof injury is often complicated by pneumothorax or hemopneumothorax. During the operation, the rupture of the pleural roof should be ligated, and if it cannot be identified, the connective tissue or muscle of the neck can be used to fill in the damage of the pleural roof in order to prevent the air from continuing to enter the pleural cavity and to promote the healing process. In addition, the air should also be extracted from the pleural cavity, and if it is a tension pneumothorax, the closed pleural cavity drainage should be performed immediately.
The accumulation of blood in the pleural cavity should be punctured as soon as it is detected, and the accumulated blood should be extracted. If the blood continues to enter the pleural cavity, it is necessary to drain the pleural cavity with closed pleural drainage, and at the same time, to stop the bleeding and give antiemetic drugs, and to transfuse blood if necessary. If there is a large amount of blood coagulation in the pleural cavity and the heart and lungs are compressed, a thoracotomy is necessary to remove the blood clots therein.
(7) Surgical management of cervical spine injury: if the patient develops progressive neurological dysfunction, or if there are fracture fragments and shrapnel present in the spinal canal, cervical laminectomy should be performed, and spinal specialists should deal with cervical spine fracture displacements or compression of the spinal cord should be reset and fixed by cranial traction method.
3. Cervical laminectomy
(1) Indications: suspected important structural injuries must expand the original wound, further exploration. The penetrating wound is caused by high-velocity gunshot, or there is obvious neck important structure injury, then should be made for cervical incision and exploration if the poke wound or is caused by low-velocity gunshot, there is no obvious neck important structure injury, whether to make a cervical incision and exploration, the opinion is not yet unanimous. However, the penetrating wound that has passed through the vastus cervicis muscle should be subjected to cervicotomy.
If the penetrating injury is located in the posterior triangle of the neck, there is no important structural injury, so it can be observed for 6 to 10 hours, and if there is no evidence of deep structural injury, it should continue to be observed. If there is hemorrhage, bleeding, hematoma formation, weak pulse, difference in blood pressure between the two arms, subcutaneous emphysema, mediastinal emphysema, pneumothorax, hemothorax, salivary leakage, air bubbles escaping, laryngeal cartilage fracture, tracheal displacement of blood in saliva, coughing up blood, dysphagia, dyspnea, hoarseness, neurological dysfunction hemiplegia, tetraplegia, cervical vertebrae fracture dislocation, etc., in the first aid treatment at the same time, should be indirect laryngoscopy , fiberoptic laryngoscope, tracheoscopy, esophagoscopy, cervical or thoracic X-ray film and CT scanning and other examinations, if necessary, cervical angiography or other examinations, in order to understand the situation in time, and then carry out cervical incision and exploration surgery.
If signs of injury to important structures in the neck appear soon after cervical dissection and exploration, relevant diagnostic measures should be taken quickly to identify the injury and a second cervical dissection and exploration can also be performed.
(2) Anesthesia method: ether inhalation anesthesia with endotracheal intubation is often used to facilitate more extensive exploration and expansion of the wound during surgery. Accompanied by cervical spine injury, should not be tracheal intubation can be used intravenous anesthesia method if the neck has a large hematoma, the laryngotracheal tube is squeezed to the side, it is not easy to insert tracheal intubation should be anesthesia before intubation, make tracheotomy.
(3) Surgical methods:
①Insertion of nasogastric tube: before skin disinfection, a nasogastric tube is inserted in order to suction gastric contents to prevent gastric dilatation, and at the same time, the esophagus can be probed for damage.
②Cutting and probing: after disinfecting the skin, from the sternal notch, along the anterior edge of the sternocleidomastoid muscle to the tip of the mastoid process, incise the subcutaneous tissue and the cervical vastus muscle, and incise the anterior edge of the sternocleidomastoid muscle fascia, and retract the sternocleidomastoid muscle to the lateral side, exposing the carotid vein and the vagus nerve in the carotid artery sheath. The sternocleidomastoid and sternocleidomastoid muscles are retracted toward the midline. If necessary, these two muscles can be cut, and the scapulohyoid muscle can also be cut for better exposure of the surgical field. If a bilateral neck exploration is needed, a collateral transverse incision can be made, similar to the incision for thyroidectomy, but in a higher and longer position.
Supraclavicular and retroclavicular vascular injuries need not be treated urgently without evidence of intrathoracic injury. Exposure of the subclavian artery injury allows removal of the inner half of the clavicle for initial arterial injury repair.
If the right subclavian artery is injured close to its origin, it must be treated by entering the thoracic cavity from the 3rd or 4th intercostal space to expose its proximal end. For right subclavian, innominate, and left common carotid artery injuries, a median sternotomy is appropriate to control hemorrhage and repair.
If the neck wound is bleeding severely, in an emergency, a finger can be inserted into the wound to compress the blood vessels to stop bleeding temporarily. Then split the sternum from the bottom up, and at the distal and proximal ends of the blood vessels, use polyester tape or umbilical cord around to rapidly stop bleeding. When the patient gradually recovered from shock, the incision could be extended to the neck, and then the blood vessels and other injuries could be treated.
If the bleeding leaks into the pleural cavity, a lateral thoracic incision should be made to control the bleeding artery distally and proximally with polyester tape or umbilical cord by pressing the bleeding with the fingers. If the department of the left side of the chest is opened to temporarily block the thoracic aorta, which helps in emergency treatment. Another incision can then be made at the anterior border of the sternocleidomastoid muscle or on the clavicle to deal with neck trauma. If the trauma involves the mediastinum and the above two incisions cannot be exposed, the full length of the sternum can be split again to facilitate operation.
The internal jugular vein rupture should be immediately compressed or ligated to avoid aspiration of air, which can cause air embolism in the circulatory system. Bleeding from the superior end of the internal jugular vein should be stopped by mastoid chiseling, exposing the sigmoid sinus and filling it with iodoform gauze strips or petroleum jelly gauze strips to compress the sigmoid sinus, which can stop bleeding.
After proper repair of the vital structures in the neck, the wound is carefully irrigated and then examined in detail. It is important to ascertain the presence of any foreign body within the surgical wound. Finally, the fascia of the anterior border of the sternocleidomastoid muscle is sutured and then the severed muscle is sutured. The sternocleidomastoid tendon of the sternocleidomastoid muscle was merged with the clavicular head tendon and sutured and fixed to the periosteum of the upper edge of the sternum, and then the subcutaneous tissue and skin were sutured to close the wound. Rubber membrane strips or cigarette-type drains are placed at each end of the wound. If the chest has been opened, the chest wall incision should also be sutured and closed chest drainage should be performed.
4. Post-operative treatment
(1) Post-operative observation: the internal cavity of the neck wound and the general condition should be closely observed after the operation, paying attention to the wound with or without redness, swelling, pressure and pain, and other infections, and with or without signs of fluid accumulation or hematoma.
(2) Wound treatment: if there is no infection or fluid accumulation in the wound, the drainage strip can be removed 24 hours after the operation; if there is infection, the drainage strip needs to be changed once every 12 to 24 hours until the infection subsides. If there is obvious pus and fluid or blood accumulation, all or part of the sutures should be removed in time, the wound should be opened with hemostatic forceps, and drainage strips should be put in, and then the dressing should be changed several times a day. If the wound is seriously infected, the wound should be opened and changed with antibiotic liquid gauze once or more times a day. If there is a lot of pus, use non-irritating saline, boric acid solution or dilute antibiotic solution to flush, and then use antibiotic liquid gauze to put inside the wound and then be bandaged. When the infection is under control and the wound grows healthy buds, a second suture or skin graft can be made.
(3) Antibiotic application: in addition to wound cleansing and dressing change, effective antibiotics should be given until the inflammation is under control.
(4) Enhancement of nutrition: patients with open neck injuries mostly use nasogastric tube or infusion to maintain their nutrition. Nasogastric tube retention time, one side of 1 ~ 2 weeks, after the expiration of a new tube, inserted from the other nostril. The use of nasogastric tube does not exclude the infusion of fluids can be supplemented with the input of hypertonic glucose, fat emulsion injection, plasma, whole blood or other nutrient solution, etc. At the same time can be injected into the therapeutic drugs. Nasogastric tube for more than l ~ 2 months, such as the need for gastrostomy or jejunostomy, insert a rubber tube, injected into the diet, in order to achieve the purpose of long-term maintenance of nutrition.
(5) the removal of tracheal tube: depending on the airway patency and the healing of open neck injuries such as the airway has been restored to patency, the wound is not a worry, should be promptly removed in accordance with the routine.