Difference between revisions of "Penetrating neck trauma"

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== WTA Algorithm ==
 
== WTA Algorithm ==
 
=== Hard Signs ===
 
=== Hard Signs ===
*Airway compromise
 
*Sub-Q emphysema/air bubbling wound
 
*Expanding or pulsatile hematoma
 
*Active bleeding
 
*Shock
 
*Neurologic deficit
 
*Hematemesis
 
 
*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.
 +
 +
{| class="wikitable sortable"
 +
|+ Hard vs. Soft Neck Signs
 +
|-
 +
! scope="col" | '''Hard Signs'''
 +
! scope="col" | '''Soft Signs'''
 +
 +
|-
 +
| Airway compromise ||Subcutaneous emphysema
 +
|-
 +
| Air bubbling wound||
 +
|-
 +
| Expanding or pulsatile hematoma||Non-pulsatile, non-expanding hematoma
 +
|-
 +
| Active Bleeding||Venous oozing
 +
|-
 +
| Shock ||Subcutaneous emphysema
 +
|-
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| Hematemesis ||Minor hematemesis
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|-
 +
| Neuro Deficit/Paralysis ||Paresthesias
 +
|}
  
 
=== Imaging ===
 
=== Imaging ===

Revision as of 13:15, 26 January 2015

Background

Algorithm for CTA Neck after penetrating trauma][1]
  • 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 w/ systemic anticoagulation

Zones of Neck

Injuries Patterns by Zone
Zone Anatomic Landmarks Potential Injuries
1 clavicle to cricoid
  1. subclavian artery and vein
  2. jugular vein
  3. common carotid artery
  4. trachea,
  5. thryroid
  6. esophagus
  7. apex of the lung
2 cricoid to angle of mandible
  1. carotid arteries
  2. internal jugular vein
  3. esophagus
  4. larynx
  5. cranial nerves X, XI, and XII
  6. spine
3 angle of mandible to base of skull
  1. lateral pharynx
  2. cranial nerves VII, IX, X, XI, and XII
  3. spine
  4. carotids

WTA Algorithm

Hard Signs

  • If hard signs or HD instability, attempt tamponade, secure airway, then OR.
  • If no hard signs and yet suspect injury, CTA.
Hard vs. Soft Neck Signs
Hard Signs Soft Signs
Airway compromise Subcutaneous emphysema
Air bubbling wound
Expanding or pulsatile hematoma Non-pulsatile, non-expanding hematoma
Active Bleeding Venous oozing
Shock Subcutaneous emphysema
Hematemesis Minor hematemesis
Neuro Deficit/Paralysis Paresthesias

Imaging

  • 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
    • Consider intubation if:
      • Stridor
      • Hemoptysis
      • Subq 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 2/2 direct cord injury or cerebral ischemia 2/2 carotid injury
    • Place in C-collar if:
      • ALOC, neuro deficits, or sig. 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

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 pt

See Also

Source

  • Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
  • Western Trauma Association critical decisions in trauma (2013)
  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]