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Neck Trauma, Penetrating, Anterior, Emergency Medicine

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Neck Trauma, Penetrating, Anterior, Emergency Medicine

Basics

Description

Larynx is located higher in neck and receives better protection from mandible and hyoid bone.

  • Wound severity gauged by violation of platysma muscle
  • Neck is divided into 3 zonesZone I: Between clavicles and cricoid cartilageInvolves vessels, lungs, trachea, esophagus, thyroidPenetrating trauma in this zone carries highest mortality owing to injury to thoracic structures.Zone II: Between cricoid cartilage and angle of mandibleInvolves vessels, trachea, esophagus, C-spine, and spinal cordInjuries are most common in this zone due to it being most exposed region.Zone III lies above angle of mandible to base of skullInjuries are difficult to access surgically
  • Zone I: Between clavicles and cricoid cartilageInvolves vessels, lungs, trachea, esophagus, thyroidPenetrating trauma in this zone carries highest mortality owing to injury to thoracic structures.
  • Zone II: Between cricoid cartilage and angle of mandibleInvolves vessels, trachea, esophagus, C-spine, and spinal cordInjuries are most common in this zone due to it being most exposed region.
  • Zone III lies above angle of mandible to base of skullInjuries are difficult to access surgically
  • Involves vessels, lungs, trachea, esophagus, thyroid
  • Penetrating trauma in this zone carries highest mortality owing to injury to thoracic structures.
  • Involves vessels, trachea, esophagus, C-spine, and spinal cord
  • Injuries are most common in this zone due to it being most exposed region.
  • Injuries are difficult to access surgically

Etiology

  • Gunshot wounds
  • Stab wounds
  • Miscellaneous (e.g., glass shards, metal fragments, animal bites)

Diagnosis

Signs and Symptoms

  • Vascular:Active/persistent hemorrhage or hematomaPulse deficitHorners syndrome (carotid injury)Vascular bruit or thrillVenous air embolism
  • Aerodigestive:Respiratory distressStridorHemoptysisTracheal deviationSC emphysemaPneumothoraxSucking woundHoarseness, aphonia, dysphoniaDysphagia/odynophagia
  • Neurologic:Central or peripheral nervous system deficits
  • Active/persistent hemorrhage or hematoma
  • Pulse deficit
  • Horners syndrome (carotid injury)
  • Vascular bruit or thrill
  • Venous air embolism
  • Respiratory distress
  • Stridor
  • Hemoptysis
  • Tracheal deviation
  • SC emphysema
  • Pneumothorax
  • Sucking wound
  • Hoarseness, aphonia, dysphonia
  • Dysphagia/odynophagia
  • Central or peripheral nervous system deficits
  • Wounds across midline increase injury significance
  • Stab woundSize of instrumentMostly low-energy penetration
  • Gunshot woundType of gun usedLong range vs. close range
  • Size of instrument
  • Mostly low-energy penetration
  • Type of gun used
  • Long range vs. close range
  • 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
  • May result in uncontrolled hemorrhage

Essential Workup

  • Platysma violationNo: Wound care, dischargeYes:Unstable: Emergent airway, ORStable: Workup depends on zone violation
  • No: Wound care, discharge
  • Yes:Unstable: Emergent airway, ORStable: Workup depends on zone violation
  • Unstable: Emergent airway, OR
  • Stable: Workup depends on zone violation

Diagnosis Tests & Interpretation

  • Type and cross-match.
  • Baseline CBC, chem panel, coags
  • 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, invasiveHelical CT angiography: Speed, noninvasiveAware of streak artifact from shoulder, poor view of subclavian vesselsEsophagram with water soluble contrast or dilute barium:Low sensitivityCombine with esophagoscopy to exclude injury.Indications: Wound approaches/crosses midline, SC air
  • Zone II:Asymptomatic: ObservationSymptomatic: OR
  • Zone III:Symptomatic: Angiography or CT angiogram
  • Angiography: Gold standard to evaluate vessel injury, invasive
  • Helical CT angiography: Speed, noninvasiveAware of streak artifact from shoulder, poor view of subclavian vessels
  • Esophagram with water soluble contrast or dilute barium:Low sensitivityCombine with esophagoscopy to exclude injury.Indications: Wound approaches/crosses midline, SC air
  • Aware of streak artifact from shoulder, poor view of subclavian vessels
  • Low sensitivity
  • Combine with esophagoscopy to exclude injury.
  • Indications: Wound approaches/crosses midline, SC air
  • Asymptomatic: Observation
  • Symptomatic: OR
  • Symptomatic: Angiography or CT angiogram
  • Bronchoscopy can be helpful in evaluating tracheal injury.
  • Surgical consult for all wounds that penetrate platysma muscleSurgical exploration:Expanding or pulsatile hematomaActive bleedingAbsence of peripheral pulsesHemoptysisHorners syndromeBruitSC emphysemaRespiratory distressAir bubbling through wound
  • Surgical exploration:Expanding or pulsatile hematomaActive bleedingAbsence of peripheral pulsesHemoptysisHorners syndromeBruitSC emphysemaRespiratory distressAir bubbling through wound
  • 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 distressStridorAir hungerLabored breathingExpanding neck hematoma
  • Nasotracheal intubation has not been proven to worsen penetrating wounds
  • Clinical signs of respiratory distress
  • Stridor
  • Air hunger
  • Labored breathing
  • Expanding neck hematoma
  • 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 indicatedBlocks direct visualization/palpation of neck; increases likelihood of missing life-threatening signs
  • 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 odynophagiaPatients 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 barotraumaCricothyroidotomy contraindicated if significant hematoma overlying cricothyroid membraneTracheostomy is warranted in this settingBreathing: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 bleedingBlind 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
  • 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 membraneTracheostomy 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
  • This is contraindicated in cases of upper airway obstruction.
  • May cause barotrauma
  • Tracheostomy is warranted in this setting
  • May require needle decompression and tube thoracostomy
  • External hemorrhage:Control with direct pressure.If failed, insert and inflate Foley catheter balloon within wound to tamponade bleedingBlind 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
  • 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.

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

  • 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.
  • 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 ƒ 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)