Penetrating neck trauma

Revision as of 23:42, 2 April 2011 by Jswartz (talk | contribs)

Background

  • Accounts for 5-10% of traumatic injuries in adults
  • Multiple structures are injured in 30% (especially if breach in platysma)

Zones

  • Zone 1: Between clavicles and inf aspect of cricoid cartilage
  • Zone 2: From cricoid cartilage superiorly to the angle of the mandible
  • Zone 3: Angle of 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