Penetrating neck trauma: Difference between revisions
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== Background == | ==Background== | ||
[[File:Neck zones.png|thumb|Zones of Neck]] | [[File:Neck zones.png|thumb|Zones of Neck]] | ||
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]] | |||
*Defined by platysma violation | *Defined by platysma violation | ||
**Assume significant injury has occurred until proven otherwise | **Assume significant injury has occurred until proven otherwise | ||
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*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 | !Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries | ||
|- | |- | ||
| 1|| | | 1||Clavicle to cricoid|| | ||
*subclavian artery and vein | *subclavian artery and vein | ||
*jugular vein | *jugular vein | ||
Line 48: | Line 25: | ||
*apex of the lung | *apex of the lung | ||
|- | |- | ||
| 2|| | | 2||Cricoid to angle of mandible|| | ||
*carotid arteries | *carotid arteries | ||
*internal jugular vein | *internal jugular vein | ||
Line 56: | Line 33: | ||
*spine | *spine | ||
|- | |- | ||
| 3|| | | 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 | ||
Line 63: | Line 40: | ||
|} | |} | ||
==Diagnosis== | ==Clinical Features== | ||
{| class="wikitable" | |||
|+ Hard vs. Soft Neck Signs | |||
|- | |||
! scope="col" | '''Hard Signs''' | |||
! scope="col" | '''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 | |||
|- | |||
| [[focal neuro deficits|Neuro Deficit]]/[[weakness|Paralysis]]/[[CVA|Cerebral ischemia]] ||[[Paresthesias]] | |||
|- | |||
| Absent or unequal radial pulse | |||
|} | |||
==Differential Diagnosis== | |||
{{Blunt neck trauma DDX}} | |||
==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 == | |||
===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]] | ||
*** | ***Subcutaneous emphysema | ||
***Expanding hematoma | ***Expanding hematoma | ||
*Breathing | *Breathing | ||
**Minimize BVM (positive pressure | **Minimize BVM (positive pressure --> air into soft tissue plains) | ||
**Consider ultrasound or CXR to eval for [[pneumothorax|PTX]], especially if Zone I injury | |||
*Circulation | *Circulation | ||
**Place IV on contralateral side of injury | **Place IV on contralateral side of injury | ||
*Disability | *Disability | ||
**Neuro deficits may be | **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 | ***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 | ||
**Platysma | **Platysma penetration | ||
*** | ***No penetration → Observe, possible discharge | ||
*** | ***Penetration + Vitals/Airway stable → CTA of neck | ||
*** | ***Penetration + Vitals/Airway unstable, or other hard signs → OR for surgical exploration | ||
*All bleeding should be controlled with pressure, not with clamps | *All bleeding should be controlled with pressure, not with clamps | ||
Line 113: | Line 114: | ||
**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 neck CT with contrast is negative, may observe patient | |||
== See Also == | ==See Also== | ||
*[[Spinal cord trauma]] | *[[Spinal cord trauma]] | ||
*[[Blunt neck trauma]] | *[[Blunt neck trauma]] | ||
*[[Head trauma (main)]] | *[[Head trauma (main)]] | ||
== References == | ==References== | ||
<references/> | <references/> | ||
[[Category:ENT]] [[Category:Trauma]] | [[Category:ENT]] [[Category:Trauma]] |
Latest revision as of 22:35, 7 February 2024
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)
- Consider ultrasound or CXR to eval for PTX, especially if Zone I injury
- 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 penetration
- No penetration → Observe, possible discharge
- Penetration + Vitals/Airway stable → CTA of neck
- Penetration + Vitals/Airway unstable, or other hard signs → OR for surgical exploration
- Platysma penetration
- 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.