Penetrating neck trauma: Difference between revisions
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*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 | *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 == | == Zones == | ||
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**Carotid/vertebral arteries, pharynx, spinal cord | **Carotid/vertebral arteries, pharynx, spinal cord | ||
== Diagnosis == | |||
=== Signs/Symptoms === | |||
*Diminished carotid pulse | *Diminished carotid pulse | ||
*Expanding hematoma | *Expanding hematoma | ||
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*Subcutaneous emphysema | *Subcutaneous emphysema | ||
=== Imaging === | |||
*CXR | *CXR | ||
**Pneumo/hemothorax, pneumomediastinum | **Pneumo/hemothorax, pneumomediastinum | ||
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***Useful if embolization or stent placement are anticipated or CT inconclusive | ***Useful if embolization or stent placement are anticipated or CT inconclusive | ||
==Management == | |||
===General=== | |||
*Airway | *Airway | ||
**If integrity of larynx is in question | **If integrity of larynx is in question trach may be safer than intubation | ||
**Consider intubation if: | **Consider intubation if: | ||
***Stridor | ***Stridor | ||
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**Place in C-collar if: | **Place in C-collar if: | ||
***ALOC, neuro deficits, or sig. blunt injury | ***ALOC, neuro deficits, or sig. blunt injury | ||
===By Zone=== | |||
====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==== | |||
*Optimal management is controversial | *Optimal management is controversial | ||
**Some advocate mandatory exploration, others favor selective operative management | **Some advocate mandatory exploration, others favor selective operative management | ||
====Zone III==== | |||
*Treat as cranial injuries | *Treat as cranial injuries | ||
*Evaluation is generally by selective, nonoperative management | *Evaluation is generally by selective, nonoperative management | ||
**Routine exploration of zone III is not indicated | **Routine exploration of zone III is not indicated | ||
===By Structure=== | |||
====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 | ||
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**Missile trajectory places esophagus at risk for injury | **Missile trajectory places esophagus at risk for injury | ||
**Persistent symptoms | **Persistent symptoms | ||
====Laryngotracheal==== | |||
*Suspect if: | *Suspect if: | ||
**Air bubbling through wound | **Air bubbling through wound | ||
Revision as of 00:15, 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
- Blunt cervical vascular injury should be treated w/ systemic anticoagulation
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
Diagnosis
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 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