Penetrating neck trauma: Difference between revisions
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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 | ||
Line 7: | Line 8: | ||
*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 | *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''' | |||
|- | |||
| 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 | ||
Line 15: | Line 40: | ||
|- | |- | ||
| 1||clavicle to cricoid|| | | 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|| | | 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|| | | 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 === | ===Imaging Options=== | ||
*CXR | *[[CXR]] | ||
**Pneumo/hemothorax, pneumomediastinum | **Pneumo/hemothorax, pneumomediastinum | ||
*CTA | |||
**1st line | |||
*Angiography | |||
**Gold-standard | |||
**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 | ||
Line 66: | Line 91: | ||
***Expanding hematoma | ***Expanding hematoma | ||
*Breathing | *Breathing | ||
**Minimize BVM (positive pressure | **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 | **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==== | ||
Line 80: | Line 106: | ||
====Zone II==== | ====Zone II==== | ||
*Optimal management is controversial | *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==== | ====Zone III==== | ||
*Treat as cranial injuries | *Treat as cranial injuries | ||
Line 99: | Line 130: | ||
**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 | *If CT is negative, may observe patient | ||
==Disposition== | |||
== See Also == | ==See Also== | ||
*[[Spinal cord trauma]] | |||
*[[Blunt neck trauma]] | |||
*[[Head trauma (main)]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:ENT]] [[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.