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Background
Algorithm for CTA Neck after penetrating trauma]
[1]
- 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
- Penetrating injury rarely results in unstable fracture
Zones of Neck
Injuries Patterns by Zone
Zone |
Anatomic Landmarks |
Potential Injuries
|
1 |
clavicle to cricoid |
- subclavian artery and vein
- jugular vein
- common carotid artery
- trachea,
- thryroid
- esophagus
- apex of the lung
|
2 |
cricoid to angle of mandible |
- carotid arteries
- internal jugular vein
- esophagus
- larynx
- cranial nerves X, XI, and XII
- spine
|
3 |
angle of mandible to base of skull |
- lateral pharynx
- cranial nerves VII, IX, X, XI, and XII
- spine
- carotids
|
WTA Algorithm
Hard Signs
- If hard signs or HD instability, attempt tamponade, secure airway, then OR.
- If no hard signs and yet suspect injury, CTA.
Hard vs. Soft Neck Signs
Hard Signs
|
Soft Signs
|
Airway compromise |
Subcutaneous emphysema
|
Air bubbling wound |
|
Expanding or pulsatile hematoma |
Non-pulsatile, non-expanding hematoma
|
Active Bleeding |
Venous oozing
|
Shock |
Subcutaneous emphysema
|
Hematemesis |
Minor hematemesis
|
Neuro Deficit/Paralysis |
Paresthesias
|
Imaging
- CXR
- Pneumo/hemothorax, pneumomediastinum
- CTA
- 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
- Platysma
- Not penetrated: obs and discharge
- Penetrated and vitals/airway stable: CT angio of neck
- Penetrated and unstable, expanding hematoma: OR
- All bleeding should be controlled with pressure, not with clamps
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
- Western Trauma Association critical decisions in trauma (2013)
- ↑ Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936–940. [1]