Difference between revisions of "Penetrating neck trauma"

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Penetrating Neck Injury (PNI)
+
==Background==
 +
[[File:Neck zones.png|thumb|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
  
- accounts for 5-10% of traumatic injuries in adults
+
==Clinical Features==
 +
{| class="wikitable"
 +
|+ Hard vs. Soft Neck Signs
 +
|-
 +
! scope="col" | '''Hard Signs'''
 +
! scope="col" | '''Soft Signs'''
  
- 2-6% mortality (can be as high as 65% fatal if major blood vessel is damaged)
+
|-
 +
| 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
 +
|}
  
- multiple structures are injured in 30% of patients with PNI (especially if there is a breach in the platysma)
+
==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
 +
*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==
 +
[[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.
  
Zones of the Neck
+
===Imaging Options===
 +
*[[CXR]]
 +
**Pneumo/hemothorax, pneumomediastinum
 +
*CTA
 +
**1st line
 +
*Angiography
 +
**Gold-standard
 +
**Useful if embolization or stent placement are anticipated or CT inconclusive
  
Zone 1: region between clavicles and inferior aspect of the cricoid cartilage
+
==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<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
  
Zone 2: from cricoid cartilage superiorly to the angle of the mandible
+
===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 3: angle of the mandible to base of skull
+
====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
  
Anatomical Structures at Risk:
+
==Disposition==
  
- carotid (common, internal external)
+
==See Also==
 +
*[[Spinal cord trauma]]
 +
*[[Blunt neck trauma]]
 +
*[[Head trauma (main)]]
  
- vertebral arteries
+
==References==
 +
<references/>
  
- subclavian vessels
+
[[Category:ENT]] [[Category:Trauma]]
 
 
- jugular vein
 
 
 
- brachiocephalic vein
 
 
 
- aortic arch
 
 
 
- lung apices
 
 
 
- cervical spine/cord
 
 
 
- thoracic duct
 
 
 
- brachial plexus
 
 
 
- phrenic nerve
 
 
 
- vagus nerve
 
 
 
- recurrent laryngeal nerve
 
 
 
- esophagus
 
 
 
- trachea
 
 
 
- larynx
 
 
 
- partoid/salivary glands
 
 
 
- cranial nerves 9-12
 
 
 
- floor of mouth/skull
 
 
 
 
 
 
Management
 
 
 
Airway
 
 
 
- consider early airway stabilization especially in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
 
 
 
- RSI  has been proven safe and effective
 
 
 
- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
 
 
 
- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
 
 
 
 
 
 
Surgical Management
 
 
 
Immediate Exploration if:
 
 
 
- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)
 
 
 
- HD unstable
 
 
 
- 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[[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.