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