Penetrating neck trauma: Difference between revisions
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*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 | ||
===Injuries Patterns by Zone=== | |||
{| {{table}} | |||
!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 | |||
|} | |||
==Clinical Features== | ==Clinical Features== | ||
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|- | |- | ||
| [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]] | | [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]] | ||
|- | |||
| Absent or unequal radial pulse | |||
|} | |} | ||
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==Evaluation== | ==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>]] | [[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 | *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 | *If no hard signs and yet suspect injury, CTA neck with IV contrast | ||
==Management== | ==Management== | ||
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***Expanding hematoma | ***Expanding hematoma | ||
*Breathing | *Breathing | ||
**Minimize BVM (positive pressure > 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 secondary to direct cord injury or cerebral ischemia secondary to 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, [[focal neuro deficits|neuro deficits]], or significant blunt injury | ***ALOC, [[focal neuro deficits|neuro deficits]], or significant blunt injury | ||
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==Disposition== | ==Disposition== | ||
*If CT is negative, may observe patient | *If neck CT with contrast is negative, may observe patient | ||
==See Also== | ==See Also== |
Revision as of 17:25, 23 February 2020
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
Injuries Patterns by Zone
Zone | Anatomic Landmarks | Potential Injuries |
---|---|---|
1 | Clavicle to cricoid |
|
2 | Cricoid to angle of mandible |
|
3 | Angle of mandible to base of skull |
|
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 |
Absent or unequal radial pulse |
Differential Diagnosis
Neck Trauma
- Penetrating neck trauma
- Blunt neck trauma
- Cervical injury
- Neurogenic shock
- Spinal cord injury
Evaluation
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]
- 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 only 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 neck CT with contrast is negative, may observe patient
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.