Penetrating neck trauma

Background

  • Defined by platysma violation
    • Assume significant injury has occurred until proven otherwise
    • Never probe neck wounds beneath the platysma (may disrupt hemostasis)
  • Multiple structures are injured in 50%
    • Stab wound can enter in one zone and damage another
  • Missed esophageal injury is leading cause of delayed death
  • GSW that crosses midline of 2x as likely to cause injuries to vital structures
  • Blunt cervical vascular injury should be treated with systemic anticoagulation
  • Penetrating injury rarely results in unstable fracture

Injuries Patterns by Zone

ZoneAnatomic LandmarksPotential Injuries
1Clavicle to cricoid
  • subclavian artery and vein
  • jugular vein
  • common carotid artery
  • trachea
  • thryroid
  • esophagus
  • apex of the lung
2Cricoid to angle of mandible
  • carotid arteries
  • internal jugular vein
  • esophagus
  • larynx
  • cranial nerves X, XI, and XII
  • spine
3Angle of mandible to base of skull
  • lateral pharynx
  • cranial nerves VII, IX, X, XI, and XII
  • spine
  • carotids

Clinical Features

Hard vs. Soft Neck Signs
Hard Signs Soft Signs
Airway compromiseSubcutaneous emphysema
Air bubbling woundDysphagia, dyspnea
Expanding or pulsatile hematomaNon-pulsatile, non-expanding hematoma
Active BleedingVenous oozing
Shock, compromised radial pulseChest tube air leak
HematemesisMinor hematemesis
Neuro Deficit/Paralysis/Cerebral ischemiaParesthesias
Absent or unequal radial pulse

Differential Diagnosis

Neck Trauma

Evaluation

Workup (WTA Algorithm)

  • If hard signs or hemodynamic instability, attempt tamponade, secure airway, then directly to OR for surgical exploration
  • If no hard signs and yet suspect injury, CTA neck with IV contrast

Management

General

  • Airway
    • If integrity of larynx is in question trach may be safer than intubation
    • One attempt at intubation by most experienced provider with tube one size smaller[2]
      • If failure, surgical airway should be performed
      • Emergency tracheostomy preferred to cricothyrotomy
    • Consider intubation if:
  • Breathing
    • Minimize BVM (positive pressure --> air into soft tissue plains)
    • Consider ultrasound or CXR to eval for PTX, especially if Zone I injury
  • Circulation
    • Place IV on contralateral side of injury
  • Disability
    • Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury
    • Place in C-collar only if:
      • ALOC, neuro deficits, or significant blunt injury

Zone I

  • Portable CXR
  • Evaluation is generally by selective, nonoperative management
  • Vascular control can be difficult; requires thoracic surgical approach

Zone II

  • Optimal management is controversial
    • Platysma
      • Not penetrated: obs and discharge
      • Penetrated and vitals/airway stable: CT angio of neck
      • Penetrated and unstable, expanding hematoma: OR
  • All bleeding should be controlled with pressure, not with clamps

Zone III

  • Treat as cranial injuries
  • Evaluation is generally by selective, nonoperative management
    • Routine exploration of zone III is not indicated

Esophagus

  • Injuries are often initially asymptomatic
  • Esophagoscopy or contrast esophagography indicated if:
    • CT is equivocal or abnormal
    • Missile trajectory places esophagus at risk for injury
    • Persistent symptoms

Laryngotracheal

  • Suspect if:
  • Laryngoscopy is indicated if:
    • Suspect laryngotracheal injury even if CT is negative

Disposition

  • If neck CT with contrast is negative, may observe patient

See Also

References

  1. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936–940.
  2. Newton K, Claudius I: Neck in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 44: pp 425-257.
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