Difference between revisions of "Penetrating neck trauma"

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==Background==
 
==Background==
 
+
*Defined by platysma violation
*Accounts for 5-10% of traumatic injuries in adults
+
*Multiple structures are injured in 30%
*Multiple structures are injured in 30% (especially if breach in platysma)
+
**Stab wound can enter in one zone and damage another
 +
*Surgery required in 15-20%
 +
*Missed esophageal injury is leading cause of delayed death
  
 
==Zones==  
 
==Zones==  
  
*Zone 1: Between clavicles and inf aspect of cricoid cartilage
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*Zone 1: Clavicles to inf aspect of cricoid cartilage
*Zone 2: From cricoid cartilage superiorly to the angle of the mandible
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**Highest mortality (usually due to exsanguination)
 +
*Zone 2: Inf cricoid cartilage to angle of mandible
 +
**Most commonly injuried
 
*Zone 3: Angle of mandible to base of skull
 
*Zone 3: Angle of mandible to base of skull
 
   
 
   
 
*Anatomical Structures at Risk:
 
*Anatomical Structures at Risk:
*carotid (common, internal external)
+
**Blood vessels
*vertebral arteries
+
***Carotid and vertebral arteries
*subclavian vessels
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***Brachiocephalic and subclavian vessels
*jugular vein
+
***Jugular vein
*brachiocephalic vein
+
*Lung apices
*aortic arch
+
*Spinal cord
*lung apices
+
*Thoracic duct
*cervical spine/cord
+
*Brachial plexus
*thoracic duct
+
*Phrenic and vagus nerves
*brachial plexus
+
*Esophagus
*phrenic nerve
+
**Dysphagia, hematemesis, blood in saliva
*vagus nerve
+
*Trachea
*recurrent laryngeal nerve
+
*CN 9-12
*esophagus
 
*trachea
 
*larynx
 
*partoid/salivary glands
 
*cranial nerves 9-12
 
*floor of mouth/skull
 
 
 
  
 
==Management==
 
==Management==
 
 
 
*Airway  
 
*Airway  
**Consider early airway stabilization esp in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
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**Consider intubation in:
 
+
***Stridor
- RSI  has been proven safe and effective
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***Hemoptysis
 
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***Subq emphysema
- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
+
***Expanding hematoma
 
+
***Stridor
- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
+
*Breathing
 
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**Minimize BVM (positive pressure > air into soft tissue plains)
+
*Circulation
 
+
**Place IV on contralateral side of injury
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
 
  
 +
*Imaging
 +
**CT and CTA
 +
***Useful for evaluating esophageal injury
 +
**Angiography
 +
***Useful if embolization or stent placement are anticipated
  
 
[[Category:Trauma]]
 
[[Category:Trauma]]

Revision as of 07:27, 5 April 2011

Background

  • Defined by platysma violation
  • Multiple structures are injured in 30%
    • Stab wound can enter in one zone and damage another
  • Surgery required in 15-20%
  • Missed esophageal injury is leading cause of delayed death

Zones

  • Zone 1: Clavicles to inf aspect of cricoid cartilage
    • Highest mortality (usually due to exsanguination)
  • Zone 2: Inf cricoid cartilage to angle of mandible
    • Most commonly injuried
  • Zone 3: Angle of mandible to base of skull
  • Anatomical Structures at Risk:
    • Blood vessels
      • Carotid and vertebral arteries
      • Brachiocephalic and subclavian vessels
      • Jugular vein
  • Lung apices
  • Spinal cord
  • Thoracic duct
  • Brachial plexus
  • Phrenic and vagus nerves
  • Esophagus
    • Dysphagia, hematemesis, blood in saliva
  • Trachea
  • CN 9-12

Management

  • Airway
    • Consider intubation in:
      • Stridor
      • Hemoptysis
      • Subq emphysema
      • Expanding hematoma
      • Stridor
  • Breathing
    • Minimize BVM (positive pressure > air into soft tissue plains)
  • Circulation
    • Place IV on contralateral side of injury
  • Imaging
    • CT and CTA
      • Useful for evaluating esophageal injury
    • Angiography
      • Useful if embolization or stent placement are anticipated