Difference between revisions of "Penetrating neck trauma"

 
(50 intermediate revisions by 11 users not shown)
Line 1: Line 1:
__TOC__
 
 
==Background==
 
==Background==
 +
[[File:Neck zones.png|thumb|Zones of Neck]]
 
*Defined by platysma violation
 
*Defined by platysma violation
*Multiple structures are injured in 30%
+
**Assume significant injury has occurred until proven otherwise
**Stab wound can enter in one zone and damage another
+
**Never probe neck wounds beneath the platysma (may disrupt hemostasis)
*Surgery required in 15-20%
+
*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
 
*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
  
==Zones==  
+
==Clinical Features==
 +
{| class="wikitable"
 +
|+ Hard vs. Soft Neck Signs
 +
|-
 +
! scope="col" | '''Hard Signs'''
 +
! scope="col" | '''Soft Signs'''
  
*Zone 1: Clavicles to inf aspect of cricoid cartilage
+
|-
**Highest mortality (usually due to exsanguination)
+
| Airway compromise ||Subcutaneous emphysema
*Zone 2: Inf cricoid cartilage to angle of mandible
+
|-
**Most commonly injuried
+
| Air bubbling wound||[[Dysphagia]], [[dyspnea]]
*Zone 3: Angle of mandible to base of skull
+
|-
+
| Expanding or pulsatile hematoma||Non-pulsatile, non-expanding hematoma
*Anatomical Structures at Risk:
+
|-
**Blood vessels
+
| Active Bleeding||Venous oozing
***Carotid and vertebral arteries
+
|-
***Brachiocephalic and subclavian vessels
+
| [[Shock]], compromised radial pulse ||Chest tube air leak
***Jugular vein
+
|-
*Lung apices
+
| [[Hematemesis]] ||Minor hematemesis
*Spinal cord
+
|-
*Thoracic duct
+
| [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]]
*Brachial plexus
+
|}
*Phrenic and vagus nerves
+
 
*Esophagus
+
==Differential Diagnosis==
**Dysphagia, hematemesis, blood in saliva
+
{| class="wikitable sortable"
*Trachea
+
|+Injuries Patterns by Zone
*CN 9-12
+
!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.
 +
 
 +
===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  
**Consider intubation in:
+
**If integrity of larynx is in question trach may be safer than intubation
***Stridor
+
**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>
***Hemoptysis
+
***If failure, surgical airway should be performed
***Subq emphysema
+
***Emergency [[tracheostomy]] preferred to [[cricothyrotomy]]
***Expanding hematoma
+
**Consider intubation if:  
***Stridor
+
***[[Stridor]]
*Breathing
+
***[[Hemoptysis]]
**Minimize BVM (positive pressure > air into soft tissue plains)
+
***Subcutaneous emphysema  
*Circulation
+
***Expanding hematoma  
**Place IV on contralateral side of injury
+
*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
 +
 
 +
===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)]]
  
*Imaging
+
==References==
**CT and CTA
+
<references/>
***Useful for evaluating esophageal injury
 
**Angiography
 
***Useful if embolization or stent placement are anticipated
 
  
[[Category:Trauma]]
+
[[Category:ENT]] [[Category:Trauma]]

Latest revision as of 22:24, 30 September 2019

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]
    • Consider intubation if:
  • 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:

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
  • Esophagoscopy or contrast esophagography indicated if:
    • CT is equivocal or abnormal
    • Missile trajectory places esophagus at risk for injury
    • Persistent symptoms

Laryngotracheal

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.