Penetrating neck trauma: Difference between revisions
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==Background== | ==Background== | ||
* | [[File:Neck zones.png|thumb|Zones of Neck]] | ||
*Multiple structures are injured in | *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== | ||
{| class="wikitable" | |||
|+ Hard vs. Soft Neck Signs | |||
|- | |||
! scope="col" | '''Hard Signs''' | |||
! scope="col" | '''Soft Signs''' | |||
|- | |||
*subclavian | | 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== | |||
{| class="wikitable sortable" | |||
|+Injuries Patterns by Zone | |||
!Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries | |||
|- | |||
| 1||clavicle to cricoid|| | |||
*subclavian artery and vein | |||
*jugular 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 | *esophagus | ||
*larynx | *larynx | ||
* | *cranial nerves X, XI, and XII | ||
*cranial nerves | *spine | ||
* | |- | ||
| 3||angle of mandible to base of skull|| | |||
*lateral pharynx | |||
*cranial nerves VII, IX, X, XI, and XII | |||
*spine | |||
*carotids | |||
|} | |||
==Evaluation== | |||
[[File:Cta-neck-trauma-algorithm.png|thumb|Algorithm for CTA Neck after penetrating trauma]<ref>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. [http://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsPenetratingNeckTrauma.pdf|fulltext] </ref>]] | |||
===Evaluation (WTA Algorithm)=== | |||
*If hard signs or HD instability, attempt tamponade, secure airway, then OR. | |||
*If no hard signs and yet suspect injury, CTA. | |||
===Imaging Options=== | |||
*[[CXR]] | |||
**Pneumo/hemothorax, pneumomediastinum | |||
*CTA | |||
**1st line | |||
*Angiography | |||
**Gold-standard | |||
**Useful if embolization or stent placement are anticipated or CT inconclusive | |||
==Management== | ==Management== | ||
===General=== | |||
*Airway | *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<ref>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.</ref> | |||
***If failure, surgical airway should be performed | |||
***Emergency tracheostomy preferred to cricothyrotomy | |||
**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 secondary to direct cord injury or cerebral ischemia secondary to 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 | |||
*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 patient | |||
==Disposition== | |||
==See Also== | |||
*[[Spinal cord trauma]] | |||
*[[Blunt neck trauma]] | |||
*[[Head trauma (main)]] | |||
==References== | |||
<references/> | |||
[[Category:Trauma]] | [[Category:ENT]] [[Category:Trauma]] |
Revision as of 16:45, 23 January 2017
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 |
|
Evaluation
Evaluation (WTA Algorithm)
- If hard signs or HD instability, attempt tamponade, secure airway, then OR.
- If no hard signs and yet suspect injury, CTA.
Imaging Options
- 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
- 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:
- 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 secondary to direct cord injury or cerebral ischemia secondary to 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 patient
Disposition
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.