Penetrating neck trauma

Penetrating Neck Injury (PNI)

- accounts for 5-10% of traumatic injuries in adults

- 2-6% mortality (can be as high as 65% fatal if major blood vessel is damaged)

- multiple structures are injured in 30% of patients with PNI (especially if there is a breach in the platysma)

Zones of the Neck

Zone 1: region between clavicles and inferior aspect of the cricoid cartilage

Zone 2: from cricoid cartilage superiorly to the angle of the mandible

Zone 3: angle of the mandible to base of skull

Anatomical Structures at Risk:

- carotid (common, internal external)

- vertebral arteries

- subclavian vessels

- jugular vein

- brachiocephalic vein

- aortic arch

- lung apices

- cervical spine/cord

- thoracic duct

- brachial plexus

- phrenic nerve

- vagus nerve

- recurrent laryngeal nerve

- esophagus

- trachea

- larynx

- partoid/salivary glands

- cranial nerves 9-12

- floor of mouth/skull

Management

Airway

- consider early airway stabilization especially in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma

- RSI has been proven safe and effective

- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries

- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)

Surgical Management

Immediate Exploration if:

- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)

- HD unstable

- airway compromise

Can delay surgical management for further evaluation/imaging if not

Imaging/Other studies

Plain Films

- not helpful in visualizing soft tissues/vacular structures

- can show foreign bodies, fractures, tracheal displacement, hemo/penumothorax, widened mediastinum, apical hematoma, etc

Angiography

- gold standard for evaluating vasculature

- more important for Zone 1 and 3 injuries, especially for surgical planning

CT Angio

- shows soft tissue, bone, and vascular injury

- similar results as traditional angiography

- if normal, may consider eliminating surgical exploration in zone 2 PNI in a HD stable patient

Bronchoscopy

Esophagraphy/Esophagoscopy