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


==Clinical Features==
===Injuries Patterns by Zone===
{| class="wikitable"
{| {{table}}
|+ 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
|-
| Neuro Deficit/Paralysis/Cerebral ischemia ||Paresthesias
|}
 
==Differential Diagnosis==
{| class="wikitable sortable"
|+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
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*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
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*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
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|}
|}


==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>]]
===Evaluation (WTA Algorithm) ===
===Workup (WTA Algorithm)===
*If hard signs or HD instability, attempt tamponade, secure airway, then 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


=== Imaging Options===
==Management==
*CXR
**Pneumo/hemothorax, pneumomediastinum
*CTA
**1st line
*Angiography
**Gold-standard
**Useful if embolization or stent placement are anticipated or CT inconclusive
 
==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)
**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 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
**Platysma
**Platysma penetration
***Not penetrated: obs and discharge
***No penetration → Observe, possible discharge
***Penetrated and vitals/airway stable: CT angio of neck
***Penetration + Vitals/Airway stable → CTA of neck
***Penetrated and unstable, expanding hematoma: OR
***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


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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===
*If CT is negative may observe pt


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


[[Category:ENT]] [[Category:Trauma]]
[[Category:ENT]] [[Category:Trauma]]

Latest revision as of 22:35, 7 February 2024

Background

Zones of Neck
Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
  • 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)
    • 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:

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
  • 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.