Penetrating neck trauma
Revision as of 21:08, 16 December 2015 by Rossdonaldson1 (talk | contribs)
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
Clinical Features
Hard Signs | Soft Signs |
---|---|
Airway compromise | Subcutaneous emphysema |
Air bubbling wound | Dysphagia, dyspnea |
Expanding or pulsatile hematoma | Non-pulsatile, non-expanding hematoma |
Active Bleeding | Venous oozing |
Shock, compromised radial pulse | Chest tube air leak |
Hematemesis | Minor hematemesis |
Neuro Deficit/Paralysis/Cerebral ischemia | Paresthesias |
Differential Diagnosis
Zone | Anatomic Landmarks | Potential Injuries |
---|---|---|
1 | clavicle to cricoid |
|
2 | cricoid to angle of mandible |
|
3 | angle of mandible to base of skull |
|
Diagnosis
WTA Algorithm
Hard Signs
- If hard signs or HD instability, attempt tamponade, secure airway, then OR.
- If no hard signs and yet suspect injury, CTA.
Imaging
- CXR
- Pneumo/hemothorax, pneumomediastinum
- CTA
- 1st line
- Angiography
- Gold-standard
- Useful if embolization or stent placement are anticipated or CT inconclusive
Management
General
- Airway
- If integrity of larynx is in question trach may be safer than intubation
- Consider intubation if:
- Stridor
- Hemoptysis
- Subq emphysema
- Expanding hematoma
- Breathing
- Minimize BVM (positive pressure > air into soft tissue plains)
- Circulation
- Place IV on contralateral side of injury
- Disability
- Neuro deficits may be 2/2 direct cord injury or cerebral ischemia 2/2 carotid injury
- Place in C-collar if:
- ALOC, neuro deficits, or sig. blunt injury
By Zone
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
- Platysma
- 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
By Structure
Esophagus
- Injuries are often initially asymptomatic
- If missed can lead to neck space infection, mediastinitis
- Esophagoscopy or contrast esophagography indicated if:
- CT is equivocal or abnormal
- Missile trajectory places esophagus at risk for injury
- Persistent symptoms
Laryngotracheal
- Suspect if:
- Air bubbling through wound
- Dyspnea, stridor
- Hemoptysis
- Subcutaneous emphysema
- Laryngoscopy is indicated if:
- Suspect laryngotracheal injury even if CT is negative
Disposition
- If CT is negative may observe pt
See Also
Source
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
- Western Trauma Association critical decisions in trauma (2013)