Basics
Description
- Wound severity gauged by violation of platysma muscle
- Neck is divided into 3 zones
- Zone I: Between clavicles and cricoid cartilage
- Involves vessels, lungs, trachea, esophagus, thyroid
- Penetrating trauma in this zone carries highest mortality owing to injury to thoracic structures.
- Zone II: Between cricoid cartilage and angle of mandible
- Involves vessels, trachea, esophagus, C-spine, and spinal cord
- Injuries are most common in this zone due to it being most exposed region.
- Zone III lies above angle of mandible to base of skull
- Injuries are difficult to access surgically
Larynx is located higher in neck and receives better protection from mandible and hyoid bone.
Etiology
- Gunshot wounds
- Stab wounds
- Miscellaneous (e.g., glass shards, metal fragments, animal bites)
Diagnosis
Signs and Symptoms
- Vascular:
- Active/persistent hemorrhage or hematoma
- Pulse deficit
- Horners syndrome (carotid injury)
- Vascular bruit or thrill
- Venous air embolism
- Aerodigestive:
- Respiratory distress
- Stridor
- Hemoptysis
- Tracheal deviation
- SC emphysema
- Pneumothorax
- Sucking wound
- Hoarseness, aphonia, dysphonia
- Dysphagia/odynophagia
- Neurologic:
- Central or peripheral nervous system deficits
History
- Wounds across midline increase injury significance
- Stab wound
- Size of instrument
- Mostly low-energy penetration
- Gunshot wound
- Type of gun used
- Long range vs. close range
Physical Exam
- Careful exam of wound to determine extent of injury and whether it penetrates platysma
- Wounds should never be probed blindly:
- May result in uncontrolled hemorrhage
Essential Workup
- Platysma violation
- No: Wound care, discharge
- Yes:
- Unstable: Emergent airway, OR
- Stable: Workup depends on zone violation
Diagnosis Tests & Interpretation
Lab
- Type and cross-match.
- Baseline CBC, chem panel, coags
Imaging
- Lateral neck radiograph to evaluate soft tissue injury and detect foreign bodies
- Chest radiograph to detect hemopneumothorax, mediastinal air
- Zone I:
- Angiography: Gold standard to evaluate vessel injury, invasive
- Helical CT angiography: Speed, noninvasive
- Aware of streak artifact from shoulder, poor view of subclavian vessels
- Esophagram with water soluble contrast or dilute barium:
- Low sensitivity
- Combine with esophagoscopy to exclude injury.
- Indications: Wound approaches/crosses midline, SC air
- Zone II:
- Asymptomatic: Observation
- Symptomatic: OR
- Zone III:
- Symptomatic: Angiography or CT angiogram
Diagnostic Procedures/Surgery
- Bronchoscopy can be helpful in evaluating tracheal injury.
- Surgical consult for all wounds that penetrate platysma muscle
- Surgical exploration:
- Expanding or pulsatile hematoma
- Active bleeding
- Absence of peripheral pulses
- Hemoptysis
- Horners syndrome
- Bruit
- SC emphysema
- Respiratory distress
- Air bubbling through wound
Differential Diagnosis
- Peripheral or CNS injury
- Cervical spine injury
- Associated head or thoracic trauma
Treatment
Pre-Hospital
- Frequent suctioning to clear airway of blood, secretions, or vomitus
- 2 large-bore IVs
- High-flow O2 should be provided
- BVM should be avoided for potential distortion of neck anatomy and airway compromise due to forced air through tracheolaryngeal wound into tissues
- Airway must be vigilantly monitored, as edema or expanding hematoma can progress to airway compromise.
- Indications for early oral intubation:
- Clinical signs of respiratory distress
- Stridor
- Air hunger
- Labored breathing
- Expanding neck hematoma
- Nasotracheal intubation has not been proven to worsen penetrating wounds
- Occlusive dressings should be applied to lacerations over major veins to prevent air embolism.
- Cervical spine immobilization in the absence of focal neurologic deficits is not indicated
- Blocks direct visualization/palpation of neck; increases likelihood of missing life-threatening signs
Initial Stabilization/Therapy
- Emergent intubation is indicated:
- Patients who are in respiratory distress or comatose.
- Be aware of voice change or odynophagia
- Patients who are stable without evidence of respiratory distress may be managed aggressively with prophylactic intubation or observed closely with airway equipment at bedside.
- Orotracheal intubation with rapid-sequence induction is method of choice for securing airway in penetrating neck trauma.
- Blind nasotracheal intubation is contraindicated with apnea, severe facial injury, or airway distortion.
- Fiberoptic bronchoscopic intubation is advantageous as patient may stay awake, allows direct visualization of vocal cords and injuries.
- Percutaneous transtracheal ventilation may be useful when oral or nasotracheal intubation fails:
- This is contraindicated in cases of upper airway obstruction.
- May cause barotrauma
- Cricothyroidotomy contraindicated if significant hematoma overlying cricothyroid membrane
- Tracheostomy is warranted in this setting
- Breathing:
- Zone I injury can cause pneumothorax or subclavian vein injury and hemothorax:
- May require needle decompression and tube thoracostomy
- Circulation:
- External hemorrhage:
- Control with direct pressure.
- If failed, insert and inflate Foley catheter balloon within wound to tamponade bleeding
- Blind clamping of vessels is contraindicated owing to risk of further neurovascular injury.
- Uncontrolled bleeding or hemodynamic instability: Send directly to OR.
- After intubation, throat can be packed with heavy gauze to tamponade bleeding.
- Hemothorax: Tube thoracostomy
Ed Treatment/Procedures
- Nasogastric tube should not be placed because of risk of rupturing pharyngeal hematoma.
- Prophylactic antibiotics are recommended (cefoxitin, clindamycin, penicillin G + metronidazole).
- Tetanus prophylaxis
Medication
- Cefoxitin: 2 g (peds: 80 " 160 mg/kg/d div. q6h) IV q8h or
- Clindamycin: 600 " 900 mg (peds: 25 " 40 mg/kg/d div. q6 " 8h) IV q8h or
- Penicillin G: 2.4 million U/d (peds: 150,000 " 250,000 U/kg/d) IV q4 " 6h, + metronidazole
- Metronidazole: 1 g load, then 500 mg (peds: 30 mg/kg/d div. q12h) IV q6h
In-Patient Considerations
Admission Criteria
- All patients with penetrating neck trauma should be admitted and observed for at least 24 hr.
- Observation must take place in facility capable of providing definitive surgical care.
- Patients with injuries suggesting airway or vascular injury must be admitted to ICU.
Discharge Criteria
- Asymptomatic patients who have negative studies may be discharged after 24 hr of observation.
- Patients with wounds superficial to the platysma may be discharged directly from the ED
Pearls and Pitfalls
- Failure to anticipate difficulties in airway management
- Failure to recognize impending airway compromise
Additional Reading
- M Ίnera F, Cohn S, Rivas LA. Penetrating injuries of the neck: Use of helical computed tomographic angiography. J Trauma. 2005;58(2):413 " 418.
- Ramasamy A, Midwinter M, Mahoney P, et al. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury. 2009;40(12):1342 " 1345.
- Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: Penetrating zone II neck trauma. J Trauma. 2008;64(5):1392 " 1405.
- Woo K, Magner DP, Wilson MT, et al. CT angiography in penetrating neck trauma reduces the need for operative neck exploration. Am Surg. 2005;71(9):754 " 758.
- Wolfson AB. Harwood-Nuss ' Clinical Practice of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
Codes
ICD9
- 874.01 Open wound of larynx, without mention of complication
- 874.8 Open wound of other and unspecified parts of neck, without mention of complication
- 874.9 Open wound of other and unspecified parts of neck, complicated
- 874.02 Open wound of trachea, without mention of complication
- 874.00 Open wound of larynx with trachea, without mention of complication
- 900.9 Injury to unspecified blood vessel of head and neck
ICD10
- S11.011A Laceration without foreign body of larynx, initial encounter
- S11.81XA Laceration w/o foreign body of oth part of neck, init encntr
- S11.90XA Unsp open wound of unspecified part of neck, init encntr
- S11.021A Laceration without foreign body of trachea, init encntr
- S11.82XA Laceration w foreign body of oth part of neck, init encntr
- S15.9XXA Injury of unspecified blood vessel at neck level, initial encounter
SNOMED
- 428152007 Penetrating wound of neck (disorder)
- 283457003 Stab wound of neck (disorder)
- 210385007 Open wound of larynx (disorder)
- 210386008 Open wound of trachea (disorder)
- 262937009 Injury to blood vessel of neck (disorder)
- 269167000 Open wound of larynx and trachea (disorder)
- 283545005 gunshot wound (disorder)