Penetrating neck trauma

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 w/ systemic anticoagulation

Zones of Neck

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

Diagnosis

Signs/Symptoms

• Diminished carotid pulse
• Expanding hematoma
• Air/bubbling in wound
• Hemoptysis
• Hematemesis
• Subcutaneous emphysema

Imaging

• 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
  • 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 2/2 direct cord injury or cerebral ischemia 2/2 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
  • Some advocate mandatory exploration, others favor selective operative management

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 pt

Source

• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck

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