Difference between revisions of "Penetrating neck trauma"

(Zones)
(Clinical Features)
 
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==Background==
 
==Background==
*Accounts for 5-10% of traumatic injuries in adults
+
[[File:Neck zones.png|thumb|Zones of Neck]]
*Multiple structures are injured in 30% (especially if breach in platysma)
+
*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
  
==Zones==  
+
===Injuries Patterns by Zone===
*Zone 1: Between clavicles and inf aspect of cricoid cartilage
+
{| {{table}}
*Zone 2: From cricoid cartilage superiorly to the angle of the mandible
+
!Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries
*Zone 3: Angle of mandible to base of skull
+
|-
+
| 1||Clavicle to cricoid||
*Anatomical Structures at Risk:
+
*subclavian artery and vein
*carotid (common, internal external)
 
*vertebral arteries
 
*subclavian vessels
 
 
*jugular vein
 
*jugular vein
*brachiocephalic vein
+
*common carotid artery
*aortic arch
+
*trachea
*lung apices
+
*thryroid
*cervical spine/cord
+
*esophagus
*thoracic duct
+
*apex of the lung
*brachial plexus
+
|-
*phrenic nerve
+
| 2||Cricoid to angle of mandible||
*vagus nerve
+
*carotid arteries
*recurrent laryngeal nerve
+
*internal jugular vein
 
*esophagus
 
*esophagus
*trachea
 
 
*larynx
 
*larynx
*partoid/salivary glands
+
*cranial nerves X, XI, and XII
*cranial nerves 9-12
+
*spine
*floor of mouth/skull
+
|-
 
+
| 3||Angle of mandible to base of skull||
==Management==
+
*lateral pharynx
 +
*cranial nerves VII, IX, X, XI, and XII
 +
*spine
 +
*carotids
 +
|}
  
*Airway
+
==Clinical Features==
**Consider early airway stabilization esp in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
+
{| class="wikitable"
 +
|+ Hard vs. Soft Neck Signs
 +
|-
 +
! scope="col" | '''Hard Signs'''
 +
! scope="col" | '''Soft Signs'''
  
- RSI  has been proven safe and effective
+
|-
 +
| 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]]
 +
|-
 +
| Absent or unequal radial pulse
 +
|}
  
- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
+
==Differential Diagnosis==
 +
{{Blunt neck trauma DDX}}
  
- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
+
==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>]]
 +
===Workup (WTA Algorithm)===
 +
*If hard signs or hemodynamic instability, attempt tamponade, secure airway, then directly to OR for surgical exploration
 +
*If no hard signs and yet suspect injury, CTA neck with IV contrast
  
+
==Management==
 
+
===General===
Surgical Management
+
*Airway
 
+
**If integrity of larynx is in question trach may be safer than intubation
Immediate Exploration if:
+
**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
- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)
+
***Emergency [[tracheostomy]] preferred to [[cricothyrotomy]]
 
+
**Consider intubation if:
- HD unstable
+
***[[Stridor]]
 
+
***[[Hemoptysis]]
- airway compromise
+
***Subcutaneous emphysema
 
+
***Expanding hematoma
Can delay surgical management for further evaluation/imaging if not
+
*Breathing
 
+
**Minimize BVM (positive pressure --> air into soft tissue plains)
+
*Circulation
 
+
**Place IV on contralateral side of injury
Imaging/Other studies
+
*Disability
 
+
**Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury
Plain Films
+
**Place in C-collar only if:
 
+
***ALOC, [[focal neuro deficits|neuro deficits]], or significant blunt injury
- 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
 
 
 
 
  
+
===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 neck CT with contrast is negative, may observe patient
  
 +
==See Also==
 +
*[[Spinal cord trauma]]
 +
*[[Blunt neck trauma]]
 +
*[[Head trauma (main)]]
  
 +
==References==
 +
<references/>
  
[[Category:Trauma]]
+
[[Category:ENT]] [[Category:Trauma]]

Latest revision as of 17:25, 23 February 2020

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

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

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
Absent or unequal radial pulse

Differential Diagnosis

Neck Trauma

Evaluation

Algorithm for CTA Neck after penetrating trauma][1]

Workup (WTA Algorithm)

  • If hard signs or hemodynamic instability, attempt tamponade, secure airway, then directly to OR for surgical exploration
  • If no hard signs and yet suspect injury, CTA neck with IV contrast

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 only 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 neck CT with contrast is negative, may observe patient

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.