Penetrating Neck Trauma
ABCs
Assume a difficult airway in a patient with neck trauma.
· When bag-mask ventilation proves difficult due to airway distortion or physical characteristics, perform an awake, orotracheal intubation using a sedative without a paralytic
· Pneumothorax and hemothorax are present in up to 20% of patients with penetrating neck trauma. Listen for breath sides and signs of tension physiology
· Exsanguination is the proximate cause of death in most penetrating neck injury victims, apply direct pressure to wounds, but be careful not to simultaneously occlude both carotid arteries and or obstruct the airway.
Zones of the Neck
· Classically, zone II injuries undergo surgical exploration; zone I and III wounds undergo further evaluation
· The trajectory of the penetrating object can be difficult to determine clinically, and nearly half traverse multiple zones
· Zone II is injured most
· The platysma is a thin muscle that stretches from the facial muscles to the thorax, demarcating superficial from deep wounds.
· Wounds that do not penetrate the platysma are largely not life threatening.
Diagnosis and Treatment
· Any wound deep to the platysma raises concern for damage to the vital structures of the neck
· Instruct awake and cooperative patients to cough (to check for hemoptysis), to swallow saliva (to assess for dysphagia from esophageal injury), and to speak (to evaluate for laryngeal fracture)
· Assess the patient for “hard” and “soft” signs of injury
· Nine out of 10 patients with hard signs will have an injury requiring repair and should be rapidly transferred to the operating room or angiography suite.
· Remember “HARD BRUIT”
· Treatment: depends on the vessel involved and accessibility of the lesion.
· Options vary from observation to surgical repair to angiographic embolization or stenting.
Laryngotracheal Injury
· Rare, seen in about 1 in 30,000 ED visits
· Protection by the jaw, spine, and sternum
· In patients with head and neck trauma, it is the second most common cause of death after intracranial hemorrhage
· Usually seen in the setting of polytrauma and their presenting features often do not correlate with the extent of injury
· Most injuries are due to blunt trauma rather than penetrating trauma
· When the extended neck accelerates forward, striking a steering wheel or dashboard, the laryngeal structures are compressed posteriorly against the spine
· Injuries: endolaryngeal hematomas or lacerations managed conservatively with symptomatic treatment and observation, to complete tracheal transection requiring open laryngotracheal reconstruction
· Symptoms: dysphonia, dyspnea, dysphagia, stridor, neck pain, or hemoptysis
· Physical Exam: tracheal tenderness, subcutaneous emphysema, cyanosis, or persistent air leak after chest tube placement
· Management:
o The immediate first step in managing laryngotracheal injuries is always to establish a secure airway
o A fiberoptic bronchoscope will aid in visualization and minimize further airway trauma during intubation
o Injury distal to the carina should be managed with fiberoptic bronchoscopy with endotracheal tube placement in the mainstem bronchus opposite the side of injury.
o Once the airway is secured, a complete secondary survey should be performed to identify other traumatic injuries
o A chest X-ray should be obtained to identify pneumothorax, pneumomediastinum, tracheal deviation, or subcutaneous emphysema. A computed tomography of the neck will identify laryngeal fractures or dislocations.
· The cricoid cartilage is a complete ring, and fractures occur in two locations, most commonly anterior and posterior.
o Cricoid cartilage injuries are often concomitant with thyroid cartilage fractures
o The recurrent laryngeal nerve is commonly injured in cricoid cartilage fractures
o Endolaryngeal stents may be used to repair injuries with significant mucosal damage or those that disrupt the anterior laryngeal commissure.
· Treatment: Patients with grade I and II injuries can be managed medically; grade III, IV, and V injuries typically require operative intervention.
References
Tintinallis Emergency Medicine A Comprehensive Study Guide
Hippo EM
Rosh Review