Penetrating neck trauma

Revision as of 03:55, 18 September 2013 by Timothydavie (talk | contribs) (Improved Tintinalli's citation)

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 Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
  • UpToDate