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 | *Defined by platysma violation | ||
**Assume significant injury has occurred until proven otherwise | **Assume significant injury has occurred until proven otherwise | ||
Line 9: | Line 10: | ||
*Blunt cervical vascular injury should be treated with systemic anticoagulation | *Blunt cervical vascular injury should be treated with systemic anticoagulation | ||
*Penetrating injury rarely results in unstable fracture | *Penetrating injury rarely results in unstable fracture | ||
− | |||
− | |||
− | |||
==Clinical Features== | ==Clinical Features== | ||
Line 23: | Line 21: | ||
| Airway compromise ||Subcutaneous emphysema | | Airway compromise ||Subcutaneous emphysema | ||
|- | |- | ||
− | | Air bubbling wound||Dysphagia, dyspnea | + | | Air bubbling wound||[[Dysphagia]], [[dyspnea]] |
|- | |- | ||
| Expanding or pulsatile hematoma||Non-pulsatile, non-expanding hematoma | | Expanding or pulsatile hematoma||Non-pulsatile, non-expanding hematoma | ||
Line 29: | Line 27: | ||
| Active Bleeding||Venous oozing | | Active Bleeding||Venous oozing | ||
|- | |- | ||
− | | Shock, compromised radial pulse ||Chest tube air leak | + | | [[Shock]], compromised radial pulse ||Chest tube air leak |
|- | |- | ||
− | | Hematemesis ||Minor hematemesis | + | | [[Hematemesis]] ||Minor hematemesis |
|- | |- | ||
− | | Neuro Deficit/Paralysis/Cerebral ischemia ||Paresthesias | + | | [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]] |
|} | |} | ||
Line 65: | Line 63: | ||
|} | |} | ||
− | == | + | ==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 hard signs or HD instability, attempt tamponade, secure airway, then OR. | ||
*If no hard signs and yet suspect injury, CTA. | *If no hard signs and yet suspect injury, CTA. | ||
− | === Imaging === | + | ===Imaging Options=== |
− | *CXR | + | *[[CXR]] |
**Pneumo/hemothorax, pneumomediastinum | **Pneumo/hemothorax, pneumomediastinum | ||
− | + | *CTA | |
− | + | **1st line | |
− | + | *Angiography | |
− | + | **Gold-standard | |
− | + | **Useful if embolization or stent placement are anticipated or CT inconclusive | |
− | ==Management == | + | ==Management== |
===General=== | ===General=== | ||
*Airway | *Airway | ||
− | **If integrity of larynx is in question trach may be safer than intubation | + | **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: | **Consider intubation if: | ||
− | ***Stridor | + | ***[[Stridor]] |
− | ***Hemoptysis | + | ***[[Hemoptysis]] |
− | *** | + | ***Subcutaneous emphysema |
***Expanding hematoma | ***Expanding hematoma | ||
*Breathing | *Breathing | ||
− | **Minimize BVM (positive pressure | + | **Minimize BVM (positive pressure > air into soft tissue plains) |
*Circulation | *Circulation | ||
**Place IV on contralateral side of injury | **Place IV on contralateral side of injury | ||
*Disability | *Disability | ||
− | **Neuro deficits may be | + | **Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury |
**Place in C-collar if: | **Place in C-collar if: | ||
− | ***ALOC, neuro deficits, or | + | ***ALOC, [[focal neuro deficits|neuro deficits]], or significant blunt injury |
+ | |||
===By Zone=== | ===By Zone=== | ||
====Zone I==== | ====Zone I==== | ||
− | *Portable CXR | + | *Portable [[CXR]] |
*Evaluation is generally by selective, nonoperative management | *Evaluation is generally by selective, nonoperative management | ||
*Vascular control can be difficult; requires thoracic surgical approach | *Vascular control can be difficult; requires thoracic surgical approach | ||
Line 115: | Line 117: | ||
**Routine exploration of zone III is not indicated | **Routine exploration of zone III is not indicated | ||
===By Structure=== | ===By Structure=== | ||
− | ====Esophagus==== | + | ====[[esophageal injury|Esophagus]]==== |
*Injuries are often initially asymptomatic | *Injuries are often initially asymptomatic | ||
− | **If missed can lead to neck space infection, mediastinitis | + | **If missed can lead to neck space infection, [[mediastinitis]] |
*Esophagoscopy or contrast esophagography indicated if: | *Esophagoscopy or contrast esophagography indicated if: | ||
**CT is equivocal or abnormal | **CT is equivocal or abnormal | ||
**Missile trajectory places esophagus at risk for injury | **Missile trajectory places esophagus at risk for injury | ||
**Persistent symptoms | **Persistent symptoms | ||
− | ====Laryngotracheal==== | + | ====[[tracheal injury|Laryngotracheal]]==== |
*Suspect if: | *Suspect if: | ||
**Air bubbling through wound | **Air bubbling through wound | ||
− | **Dyspnea, stridor | + | **[[Dyspnea]], [[stridor]] |
− | **Hemoptysis | + | **[[Hemoptysis]] |
**Subcutaneous emphysema | **Subcutaneous emphysema | ||
− | *Laryngoscopy is indicated if: | + | *[[Laryngoscopy]] is indicated if: |
**Suspect laryngotracheal injury even if CT is negative | **Suspect laryngotracheal injury even if CT is negative | ||
===Disposition=== | ===Disposition=== | ||
− | *If CT is negative may observe | + | *If CT is negative, may observe patient |
+ | |||
+ | ==Disposition== | ||
− | == See Also == | + | ==See Also== |
*[[Spinal cord trauma]] | *[[Spinal cord trauma]] | ||
*[[Blunt neck trauma]] | *[[Blunt neck trauma]] | ||
*[[Head trauma (main)]] | *[[Head trauma (main)]] | ||
− | == References == | + | ==References== |
<references/> | <references/> | ||
− | |||
− | |||
[[Category:ENT]] [[Category:Trauma]] | [[Category:ENT]] [[Category:Trauma]] |
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.