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Background
Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
- 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
Zone |
Anatomic Landmarks |
Potential Injuries
|
1 |
Clavicle to cricoid |
- subclavian artery and vein
- jugular vein
- common carotid artery
- trachea
- thryroid
- esophagus
- apex of the lung
|
2 |
Cricoid to angle of mandible |
- carotid arteries
- internal jugular vein
- esophagus
- larynx
- cranial nerves X, XI, and XII
- spine
|
3 |
Angle of mandible to base of skull |
- lateral pharynx
- cranial nerves VII, IX, X, XI, and XII
- spine
- carotids
|
Clinical Features
Differential Diagnosis
Evaluation
Algorithm for CTA Neck after penetrating trauma]
[1]
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]
- 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:
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 penetration
- No penetration → Observe, possible discharge
- Penetration + Vitals/Airway stable → CTA of neck
- Penetration + Vitals/Airway unstable, or other hard signs → OR for surgical exploration
- 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
- 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
- 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
- ↑ 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. [1]
- ↑ 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.