Difference between revisions of "Penetrating neck trauma"

(Addition of trauma algorithm)
(Clinical Features)
 
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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 7: Line 8:
 
*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
 
*GSW that crosses midline of 2x as likely to cause injuries to vital structures
*Blunt cervical vascular injury should be treated w/ systemic anticoagulation
+
*Blunt cervical vascular injury should be treated with systemic anticoagulation
 +
*Penetrating injury rarely results in unstable fracture
  
===Zones of Neck===
+
===Injuries Patterns by Zone===
{| class="wikitable sortable"
+
{| {{table}}
|+Injuries Patterns by Zone
 
 
!Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries
 
!Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries
 
|-
 
|-
| 1||clavicle to cricoid||
+
| 1||Clavicle to cricoid||
#subclavian artery and vein
+
*subclavian artery and vein
#jugular vein
+
*jugular vein
#common carotid artery
+
*common carotid artery
#trachea,
+
*trachea
#thryroid
+
*thryroid
#esophagus
+
*esophagus
#apex of the lung
+
*apex of the lung
 
|-
 
|-
| 2||cricoid to angle of mandible||
+
| 2||Cricoid to angle of mandible||
#carotid arteries
+
*carotid arteries
#internal jugular vein
+
*internal jugular vein
#esophagus
+
*esophagus
#larynx
+
*larynx
#cranial nerves X, XI, and XII
+
*cranial nerves X, XI, and XII
#spine
+
*spine
 
|-
 
|-
| 3||angle of mandible to base of skull||
+
| 3||Angle of mandible to base of skull||
#lateral pharynx
+
*lateral pharynx
#cranial nerves VII, IX, X, XI, and XII
+
*cranial nerves VII, IX, X, XI, and XII
#spine
+
*spine
#carotids
+
*carotids
 
|}
 
|}
  
== WTA Algorithm ==
+
==Clinical Features==
=== Hard Signs ===
+
{| class="wikitable"
*Airway compromise
+
|+ Hard vs. Soft Neck Signs
*Sub-Q emphysema/air bubbling wound
+
|-
*Expanding or pulsatile hematoma
+
! scope="col" | '''Hard Signs'''
*Active bleeding
+
! scope="col" | '''Soft Signs'''
*Shock
+
 
*Neurologic deficit
+
|-
*Hematemesis
+
| Airway compromise ||Subcutaneous emphysema
*If hard signs or HD instability, attempt tamponade, secure airway, then OR.
+
|-
*If no hard signs and yet suspect injury, CTA.
+
| 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
 +
|}
  
=== Imaging ===
+
==Differential Diagnosis==
*CXR
+
{{Blunt neck trauma DDX}}
**Pneumo/hemothorax, pneumomediastinum
 
**CTA
 
***1st line
 
**Angiography
 
***Gold-standard
 
***Useful if embolization or stent placement are anticipated or CT inconclusive
 
  
==Management ==
+
==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===
 
===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]]
***Subq emphysema  
+
***Subcutaneous emphysema  
 
***Expanding hematoma  
 
***Expanding hematoma  
 
*Breathing  
 
*Breathing  
**Minimize BVM (positive pressure &gt; air into soft tissue plains)  
+
**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 2/2 direct cord injury or cerebral ischemia 2/2 carotid injury  
+
**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 only if:  
***ALOC, neuro deficits, or sig. blunt injury
+
***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
 
====Zone II====
 
====Zone II====
 
*Optimal management is controversial
 
*Optimal management is controversial
**Some advocate mandatory exploration, others favor selective operative management
+
**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====
 
====Zone III====
 
*Treat as cranial injuries
 
*Treat as cranial injuries
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**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 pt
+
*If neck CT with contrast is negative, may observe patient
  
== See Also ==
+
==See Also==
 +
*[[Spinal cord trauma]]
 +
*[[Blunt neck trauma]]
 +
*[[Head trauma (main)]]
  
== Source ==
+
==References==
*Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
 
*Western Trauma Association critical decisions in trauma (2013)
 
 
<references/>
 
<references/>
  
 
[[Category:ENT]] [[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.