Penetrating neck trauma

Revision as of 06:44, 5 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 esp 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