Penetrating Neck Injuries
Background
· 1% of all trauma admissions
· 5% mortality rate
vascular injuries most common cause
20% mortality secondary to uncontrolled hemorrhage
missed esophageal injury = highest cause of delayed death in this population
· up to 20% have tracheobronchial injuries
· Many important structures in the neck
Divided into different levels or “ZONES”
· Zone I: clavicles/angle of sternum to cricoid cartilage
o Contains proximal portion of common carotid artery, subclavian artery, vertebral artery, lung apices, trachea, thyroid, esophagus, thoracic duct, spinal cord
· Zone II: Cricoid cartilage to angle of the mandible
o Contains carotid artery, vertebral artery, jugular veins, pharynx, trachea, esophagus, larynx, vagus nerve, recurrent laryngeal nerve, spinal cord
o Traditionally, went to OR for exploration (see below)
· Zone III: angle of mandible to base of skull
o Vertebral artery, distal carotid artery, salivary and parotid glands, spinal cord, CN 9 through 12, spinal cord
· *penetrating injuries can involve more than one zone
· * platysma muscle sits between superficial and deep cervical fascia (see below)
mostly in Zone II (and part of III)
penetration of platysma increases chance of serious injury
previously, all of these patients went to OR. now, can obtain CTA neck if stable and don’t meet hard signs (see below)
Management
o A.B.Cs, A.B.Cs, and some more A.B.Cs (+D.E.F…never forget full exposure in your penetrating trauma, in between groin, under axilla, etc.)
Monitor for exsanguination and asphyxiation
o Violation of the platysmaàCTA neck (stable) vs. OR (unstable or hard signs)
o Hard and soft signs to further classify severity of injury (chart below)
90% rate of major injury with hard signs!
If ANY of the hard signs or hemodynamic instability are present—> OR
no pit stop to the CT scanner
only to be delayed to secure unstable airway or tamponade bleeding
If only soft signs (+stable) are presentà CTA neck vs. observation
Obtain ct if concern for vascular trauma
If imaging negative observation
o CXR to rule out pneumo/hemothoax
Airway
o If hard signs present, consider intubating early
o Expanding hematoma can cause airway obstruction; hematemesis can make visualization difficult
o Prepare (“mark the neck”) for surgical airway if necessary
o If suspect tracheal injury, then use a .5 size smaller
o Consider awake intubation or ketamine only
o To reduce chance of obstruction from muscle relaxation secondary to paralytics
o Do not vigorously BVM
o Positive pressure can worsen injury and introduce air into neck space
Breathing
o Remember lung apices in Zone Iàcan lead to pneumo/hemoX
o Preform US/obtain CXR
Bleeding
o Direct pressure
o If cant control with pressure, then place a foley catheter through wound and inflate balloon to tamponade as temporizing measure (see image below)
o But try not to probe/dig around as you can dislodge a clot
