Difference between revisions of "Penetrating neck trauma"

(Zones)
Line 8: Line 8:
 
*Zone 3: Angle of mandible to base of skull
 
*Zone 3: Angle of mandible to base of skull
 
   
 
   
 +
*Anatomical Structures at Risk:
 +
*carotid (common, internal external)
 +
*vertebral arteries
 +
*subclavian vessels
 +
*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
  
Anatomical Structures at Risk:
+
==Management==
  
- carotid (common, internal external)
+
*Airway  
 
+
**Consider early airway stabilization esp in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
- vertebral arteries
 
 
 
- subclavian vessels
 
 
 
- 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
 
- RSI  has been proven safe and effective

Revision as of 02:28, 4 April 2011

Background

  • Accounts for 5-10% of traumatic injuries in adults
  • Multiple structures are injured in 30% (especially if breach in platysma)

Zones

  • Zone 1: Between clavicles and inf aspect of cricoid cartilage
  • Zone 2: From cricoid cartilage superiorly to the angle of the mandible
  • Zone 3: Angle of mandible to base of skull
  • Anatomical Structures at Risk:
  • carotid (common, internal external)
  • vertebral arteries
  • subclavian vessels
  • 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 esp 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