Difference between revisions of "Penetrating neck trauma"

m (moved Penetrating Neck Injury to Neck Trauma: Better title)
Line 1: Line 1:
==Background==
+
== Background ==
 
*Defined by platysma violation
 
*Defined by platysma violation
*Multiple structures are injured in 30%
+
**Assume significant injury has occurred until proven otherwise
**Stab wound can enter in one zone and damage another
+
**Never probe neck wounds beneath the platysma (may disrupt hemostasis)
*Surgery required in 15-20%
+
*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
 
*Missed esophageal injury is leading cause of delayed death
 +
*GSW that crosses midline of 2x as likely to cause injuries to vital structures
  
==Diagnosis==
+
== Diagnosis ==
===Zones===
+
=== Zones ===
 +
*Zone 1: Clavicles to cricoid cartilage
 +
**Carotid/vertebral arteries, lungs, esophagus, trachea, thoracic duct, spinal cord
 +
*Zone 2: Cricoid cartilage to angle of mandible
 +
**Carotid/vertebral arteries, jugular vein, esophagus, trachea, larynx, spinal cord
 +
*Zone 3: Angle of mandible to base of skull
 +
**Carotid/vertebral arteries, pharynx, spinal cord
  
*Zone 1: Clavicles to inf aspect of cricoid cartilage
+
=== Signs/Symptoms ===
**Highest mortality (usually due to exsanguination)
+
*Diminished carotid pulse
*Zone 2: Inf cricoid cartilage to angle of mandible
+
*Expanding hematoma
**Most commonly injuried
+
*Air/bubbling in wound
*Zone 3: Angle of mandible to base of skull
+
*Hemoptysis
+
*Hematemesis
*Anatomical Structures at Risk:
+
*Subcutaneous emphysema
**Blood vessels
 
***Carotid and vertebral arteries
 
***Brachiocephalic and subclavian vessels
 
***Jugular vein
 
*Lung apices
 
*Spinal cord
 
*Thoracic duct
 
*Brachial plexus
 
*Phrenic and vagus nerves
 
*Esophagus
 
**Dysphagia, hematemesis, blood in saliva
 
*Trachea
 
*CN 9-12
 
  
===Imaging===
+
=== Imaging ===
*Imaging
+
*CXR
**CT and CTA
+
**Pneumo/hemothorax, pneumomediastinum
***Useful for evaluating esophageal injury
+
**CTA  
**Angiography
+
***1st line
***Useful if embolization or stent placement are anticipated
+
**Angiography  
 +
***Gold-standard
 +
***Useful if embolization or stent placement are anticipated or CT inconclusive
  
==Treatment==
+
==Management ==
 +
===General===
 
*Airway  
 
*Airway  
**Consider intubation in:
+
**If integrity of larynx is in question cric/trach may be safer than intubation
***Stridor
+
**Consider intubation if:  
***Hemoptysis
+
***Stridor  
***Subq emphysema
+
***Hemoptysis  
***Expanding hematoma
+
***Subq emphysema  
***Stridor
+
***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
 +
**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
 +
**Some advocate mandatory exploration, others favor selective operative management
 +
====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
  
==See Also==
+
==Disposition==
 +
*If CT is negative may observe pt
  
[[Category:ENT]]
+
== See Also ==
[[Category:Trauma]]
+
 
 +
== Source ==
 +
*Tintinalli's
 +
*UpToDate
 +
 
 +
[[Category:ENT]] [[Category:Trauma]]

Revision as of 00:07, 17 July 2011

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

Diagnosis

Zones

  • Zone 1: Clavicles to cricoid cartilage
    • Carotid/vertebral arteries, lungs, esophagus, trachea, thoracic duct, spinal cord
  • Zone 2: Cricoid cartilage to angle of mandible
    • Carotid/vertebral arteries, jugular vein, esophagus, trachea, larynx, spinal cord
  • Zone 3: Angle of mandible to base of skull
    • Carotid/vertebral arteries, pharynx, spinal cord

Signs/Symptoms

  • Diminished carotid pulse
  • Expanding hematoma
  • Air/bubbling in wound
  • Hemoptysis
  • Hematemesis
  • Subcutaneous emphysema

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 cric/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
    • Some advocate mandatory exploration, others favor selective operative management

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
  • UpToDate