Difference between revisions of "Penetrating neck trauma"

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==Background==
 
==Background==
*Accounts for 5-10% of traumatic injuries in adults
+
[[File:Neck zones.png|thumb|Zones of Neck]]
*Multiple structures are injured in 30% (especially if breach in platysma)
+
*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
  
==Zones==  
+
==Clinical Features==
*Zone 1: Between clavicles and inf aspect of cricoid cartilage
+
{| class="wikitable"
*Zone 2: From cricoid cartilage superiorly to the angle of the mandible
+
|+ Hard vs. Soft Neck Signs
*Zone 3: Angle of mandible to base of skull
+
|-
+
! scope="col" | '''Hard Signs'''
*Anatomical Structures at Risk:
+
! scope="col" | '''Soft Signs'''
*carotid (common, internal external)
+
 
*vertebral arteries
+
|-
*subclavian vessels
+
| 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
*brachiocephalic vein
+
*common carotid artery
*aortic arch
+
*trachea
*lung apices
+
*thryroid
*cervical spine/cord
+
*esophagus
*thoracic duct
+
*apex of the lung
*brachial plexus
+
|-
*phrenic nerve
+
| 2||cricoid to angle of mandible||
*vagus nerve
+
*carotid arteries
*recurrent laryngeal nerve
+
*internal jugular vein
 
*esophagus
 
*esophagus
*trachea
 
 
*larynx
 
*larynx
*partoid/salivary glands
+
*cranial nerves X, XI, and XII
*cranial nerves 9-12
+
*spine
*floor of mouth/skull
+
|-
 +
| 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  
**Consider early airway stabilization esp in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
+
**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>
- RSI  has been proven safe and effective
+
***If failure, surgical airway should be performed
 
+
***Emergency tracheostomy preferred to cricothyrotomy
- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
+
**Consider intubation if:
 
+
***Stridor
- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
+
***Hemoptysis
 
+
***Subq emphysema
+
***Expanding hematoma
 
+
*Breathing
Surgical Management
+
**Minimize BVM (positive pressure > air into soft tissue plains)
 
+
*Circulation
Immediate Exploration if:
+
**Place IV on contralateral side of injury
 
+
*Disability
- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)
+
**Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury
 
+
**Place in C-collar if:
- HD unstable
+
***ALOC, neuro deficits, or sig. blunt injury
 
 
- airway compromise
 
 
 
Can delay surgical management for further evaluation/imaging if not
 
 
 
 
 
 
Imaging/Other studies
 
 
 
Plain Films
 
 
 
- not helpful in visualizing soft tissues/vacular structures
 
 
 
- can show foreign bodies, fractures, tracheal displacement, hemo/penumothorax, widened mediastinum, apical hematoma, etc
 
 
 
 
 
 
Angiography
 
 
 
- gold standard for evaluating vasculature
 
 
 
- more important for Zone 1 and 3 injuries, especially for surgical planning
 
 
 
 
 
 
CT Angio
 
 
 
- shows soft tissue, bone, and vascular injury
 
 
 
- similar results as traditional angiography
 
 
 
- if normal, may consider eliminating surgical exploration in zone 2 PNI in a HD stable patient
 
 
 
 
 
 
Bronchoscopy
 
 
 
Esophagraphy/Esophagoscopy
 
  
+
===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

Zones of Neck
  • 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 vs. Soft Neck Signs
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

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

Evaluation

Algorithm for CTA Neck after penetrating trauma][1]

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
  • 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

  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. [1]
  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.