Difference between revisions of "Penetrating neck trauma"

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== Background ==
+
==Background==
 +
[[File:Neck zones.png|thumb|Zones of Neck]]
 
*Defined by platysma violation
 
*Defined by platysma violation
 
**Assume significant injury has occurred until proven otherwise  
 
**Assume significant injury has occurred until proven otherwise  
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*Missed esophageal injury is leading cause of delayed death
 
*Missed esophageal injury is leading cause of delayed death
 
*GSW that crosses midline of 2x as likely to cause injuries to vital structures
 
*GSW that crosses midline of 2x as likely to cause injuries to vital structures
*Blunt cervical vascular injury should be treated w/ systemic anticoagulation
+
*Blunt cervical vascular injury should be treated with systemic anticoagulation
 +
*Penetrating injury rarely results in unstable fracture
  
===Zones of Neck===
+
==Clinical Features==
 +
{| class="wikitable"
 +
|+ Hard vs. Soft Neck Signs
 +
|-
 +
! scope="col" | '''Hard Signs'''
 +
! scope="col" | '''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==
 
{| class="wikitable sortable"
 
{| class="wikitable sortable"
 
|+Injuries Patterns by Zone
 
|+Injuries Patterns by Zone
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|-
 
|-
 
| 1||clavicle to cricoid||
 
| 1||clavicle to cricoid||
#subclavian artery and vein
+
*subclavian artery and vein
#jugular vein
+
*jugular vein
#common carotid artery
+
*common carotid artery
#trachea,
+
*trachea
#thryroid
+
*thryroid
#esophagus
+
*esophagus
#apex of the lung
+
*apex of the lung
 
|-
 
|-
 
| 2||cricoid to angle of mandible||
 
| 2||cricoid to angle of mandible||
#carotid arteries
+
*carotid arteries
#internal jugular vein
+
*internal jugular vein
#esophagus
+
*esophagus
#larynx
+
*larynx
#cranial nerves X, XI, and XII
+
*cranial nerves X, XI, and XII
#spine
+
*spine
 
|-
 
|-
 
| 3||angle of mandible to base of skull||
 
| 3||angle of mandible to base of skull||
#lateral pharynx
+
*lateral pharynx
#cranial nerves VII, IX, X, XI, and XII
+
*cranial nerves VII, IX, X, XI, and XII
#spine
+
*spine
#carotids
+
*carotids
 
|}
 
|}
  
== Diagnosis ==
+
==Evaluation==
=== Signs/Symptoms ===
+
[[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>]]
*Diminished carotid pulse
+
===Evaluation (WTA Algorithm)===
*Expanding hematoma
+
*If hard signs or HD instability, attempt tamponade, secure airway, then OR.
*Air/bubbling in wound
+
*If no hard signs and yet suspect injury, CTA.
*Hemoptysis
 
*Hematemesis
 
*Subcutaneous emphysema
 
  
=== Imaging ===
+
===Imaging Options===
*CXR  
+
*[[CXR]]
 
**Pneumo/hemothorax, pneumomediastinum  
 
**Pneumo/hemothorax, pneumomediastinum  
**CTA  
+
*CTA  
***1st line
+
**1st line
**Angiography  
+
*Angiography  
***Gold-standard
+
**Gold-standard
***Useful if embolization or stent placement are anticipated or CT inconclusive
+
**Useful if embolization or stent placement are anticipated or CT inconclusive
  
==Management ==
+
==Management==
 
===General===
 
===General===
 
*Airway  
 
*Airway  
**If integrity of larynx is in question trach may be safer than intubation  
+
**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:  
 
**Consider intubation if:  
 
***Stridor  
 
***Stridor  
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***Expanding hematoma  
 
***Expanding hematoma  
 
*Breathing  
 
*Breathing  
**Minimize BVM (positive pressure &gt; air into soft tissue plains)  
+
**Minimize BVM (positive pressure > air into soft tissue plains)  
 
*Circulation  
 
*Circulation  
 
**Place IV on contralateral side of injury  
 
**Place IV on contralateral side of injury  
 
*Disability  
 
*Disability  
**Neuro deficits may be 2/2 direct cord injury or cerebral ischemia 2/2 carotid injury  
+
**Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury  
 
**Place in C-collar if:  
 
**Place in C-collar if:  
 
***ALOC, neuro deficits, or sig. blunt injury
 
***ALOC, neuro deficits, or sig. blunt injury
 +
 
===By Zone===
 
===By Zone===
 
====Zone I====
 
====Zone I====
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====Zone II====
 
====Zone II====
 
*Optimal management is controversial
 
*Optimal management is controversial
**Some advocate mandatory exploration, others favor selective operative management
+
**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====
 
====Zone III====
 
*Treat as cranial injuries
 
*Treat as cranial injuries
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**Hemoptysis
 
**Hemoptysis
 
**Subcutaneous emphysema
 
**Subcutaneous emphysema
*Laryngoscopy is indicated if:
+
*[[Laryngoscopy]] is indicated if:
 
**Suspect laryngotracheal injury even if CT is negative
 
**Suspect laryngotracheal injury even if CT is negative
  
 
===Disposition===
 
===Disposition===
*If CT is negative may observe pt
+
*If CT is negative, may observe patient
 +
 
 +
==Disposition==
  
== See Also ==
+
==See Also==
 +
*[[Spinal cord trauma]]
 +
*[[Blunt neck trauma]]
 +
*[[Head trauma (main)]]
  
== Source ==
+
==References==
*Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
+
<references/>
*UpToDate
 
  
 
[[Category:ENT]] [[Category:Trauma]]
 
[[Category:ENT]] [[Category:Trauma]]

Latest 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.