Difference between revisions of "Penetrating neck trauma"
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==Background== | ==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 | ||
− | + | ==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 | ||
+ | |- | ||
+ | | [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]] | ||
+ | |} | ||
− | + | ==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 | |
− | *subclavian | ||
*jugular 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 | *esophagus | ||
− | |||
*larynx | *larynx | ||
− | * | + | *cranial nerves X, XI, and XII |
− | *cranial nerves | + | *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. | ||
+ | ===Imaging Options=== | ||
+ | *[[CXR]] | ||
+ | **Pneumo/hemothorax, pneumomediastinum | ||
+ | *CTA | ||
+ | **1st line | ||
+ | *Angiography | ||
+ | **Gold-standard | ||
+ | **Useful if embolization or stent placement are anticipated or CT inconclusive | ||
==Management== | ==Management== | ||
− | + | ===General=== | |
− | |||
*Airway | *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]] | |
− | + | ***Subcutaneous 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, [[focal neuro deficits|neuro deficits]], or significant blunt injury |
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− | - | ||
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− | + | ===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=== | ||
+ | ====[[esophageal injury|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 | ||
+ | ====[[tracheal injury|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== | |
+ | *[[Spinal cord trauma]] | ||
+ | *[[Blunt neck trauma]] | ||
+ | *[[Head trauma (main)]] | ||
+ | ==References== | ||
+ | <references/> | ||
− | [[Category:Trauma]] | + | [[Category:ENT]] [[Category:Trauma]] |
Latest revision as of 22:24, 30 September 2019
Contents
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

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
- Subcutaneous 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 significant 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.