Penetrating Neck Trauma

See Also

Definitions

Penetrating Neck Trauma
1. Injury with penetration of the platysma Muscle

Precautions

First priorities in Penetrating Neck Trauma are Airway and Vascular Injury
1. See ABC Management
Assume a dynamic airway
1. Neck Hematomas and subcutaneous edema increase over time
2. Reassess the airway frequently for developing obstruction
Do not be distracted by the actual neck wound
1. Hold pressure on the wound and complete the Trauma survey

Symptoms

Dysphagia
Hoarseness
Bleeding from nose or mouth
Neurologic deficit
Hypotension

Signs

Subcutaneous Emphysema
Stridor
Respiratory distress
Expanding Hematoma
Active bleeding from wound site
Carotid Bruit
Loss of pulse
Neurologic deficit
1. CNS findings may be due to ischemia
2. Unilateral motor deficits or dermatomal sensory changes (consider nerve injury proximal to the Brachial Plexus)

Exam
Wound Evaluation

Clean blood from wound
Determine if platysma was breached (if possible)
Estimate wound depth and trajectory based on observation
1. Avoid probing neck wounds to determine depth

Exam
Localization of underlying injuries

Determine depth of penetrating injury
1. Injuries superficial to the platysma Muscle may be repaired in normal fashion
2. Injuries deep to the platysma Muscle are high risk for serious injuries to underlying major structures
  1. Requires CT angiography and possible surgical exploration
Determine anterior triangle or posterior triangle injury
1. Anterior triangle (Anterior to sternocleidomastoid)
  1. Most major structures (major vessels, trachea, Esophagus)
2. Posterior triangle (Posterior to sternocleidomastoid)
  1. Spinal Column (rare injury from Spinal Trauma)
3. Images
Determine Zone of injury (Zone 1 inferiorly to Zone 3 superiorly)
1. Precautions
  1. Most neck injuries are not limited to one zone
    1. Patients have typically been stabbed multiple times
    2. Neck wounds (esp. Gunshot Wounds) typically cut across neck zones
  2. Injury zones play a reduced role in current day Penetrating Neck Trauma
    1. As of 2013, evaluation is exam-based with CT Angiography
    2. See evaluation protocol below
  3. Injury zones were originally developed to risk stratify patients based on ease of surgical exploration
    1. Zone 2 injuries are less difficult to explore than Zone 1 and 3
    2. Zone 2 Penetrating Trauma was typically explored in OR
      1. Resulted in a large number of unnecessary explorations
    3. Zone 1 and 3 Penetrating Trauma evaluation is more difficult
      1. Typically required complicated evaluation protocols including standard angiogram
2. Zone 1 (sternal notch to cricoid ring/clavicle head)
  1. Lung apex (injury results in Pneumothorax, Hemothorax)
  2. Common Carotid Artery
  3. Subclavian artery
  4. Vertebral Artery
3. Zone 2 (cricoid ring to angle of Mandible) - Highest risk region (but most accessible to exploration)
  1. Internal Carotid Artery
  2. Internal Jugular Vein
  3. Sympathetic trunk (injury results in Hypotension)
  4. Recurrent laryngeal nerve (injury results in Hoarseness)
  5. Trachea
  6. Larynx
  7. Esophagus
4. Zone 3 (angle of Mandible to skull base)
  1. Vertebral Artery
  2. External Carotid Artery
Determine trajectory
1. Penetrating injury toward vital structures (e.g. medial trajectory) or
2. Penetrating injury away from vital structures (e.g. lateral trajectory)

Evaluation

Immediate surgery indications (hard signs of serious injury)
1. Arterial injury
  1. Cerebral ischemia (e.g. new Hemiplegia suggesting carotid injury)
  2. Unstable Patient with shock assumed secondary to neck Trauma
  3. Expanding or pulsatile Hematoma
  4. Severe active bleeding (pulsatile bleeding, arterial bleeding)
  5. Refractory shock state
  6. Radial pulse diminished or absent on the side of injury
  7. Arterial Bruit or thrill
2. Aerodigestive injury (less common)
  1. Airway obstruction
  2. Hemoptysis
  3. Hematemesis
  4. Wound with air bubbling through
Intermediate or Soft Signs (platysma penetration without hard signs)
1. Soft Sign Indications
  1. Stable neck Hematoma
  2. Hoarseness
  3. Dysphagia
  4. Mild subcutaneous Emphysema
  5. Minor Hematemesis
  6. Minor Hemoptysis
2. CT Angiography of Neck in most patients
3. Consult with Trauma surgery for local protocols
Asymptomatic Patients (no hard or soft signs) AND no platysma penetration
1. Close neck wound
2. May discharge home if no complications on serial examination
CT Angiography of Neck based decision making
1. Obvious CTA abnormalities requiring operative management
  1. Immediate surgery
2. Intermediate CTA findings (possible aerodigestive injuries): Options for evaluation
  1. Bronchoscopy
  2. Laryngoscopy
  3. Upper endoscopy
  4. Barium Swallow
  5. Endovascular intervention (e.g. posterior vascular injury, such as Vertebral Artery injury)
3. No obvious CTA abnormalities to indicate immediate surgery
  1. Consult local Trauma surgery for recommendations
  2. Penetration trajectory toward vital structures
    1. Admit for observation
  3. Penetration trajectory away from vital structures
    1. Observe for 6-12 hours
    2. May discharge if stable following observation

Management

General
1. ABC Management
2. See Trauma Primary Survey
3. See Trauma Secondary Survey
4. See Penetrating Trauma
Alert Trauma surgery as early as possible
1. If no Trauma surgery available at facility, arrange emergent transport
2. Defer imaging to the receiving facility if no means to manage findings at initial site
Cervical Spine Immobilization indications
1. Neurologic deficit
2. Altered Level of Consciousness
Bleeding control
1. Apply direct pressure (firmly with fingers, not an inserted gauze wad)
2. Avoid removing A bandage if adequate control (esp. if heavier or pulsatile bleeding prior to bandage)
3. Do not clamp due to significant risk of collateral damage
4. Bleeding refractory to pressure
  1. Consider inserting a foley into wound and inflating with saline
5. Consider initiating Massive Transfusion Protocol early
Venous access
1. Obtain on opposite side of injury
Patient cooperation may be difficult due to anxiousness, airway compromise
1. Consider dissociative dose Ketamine (e.g. 1 mg/kg IV) during the Trauma survey and stabilization
Advanced Airway management (intubation, Cricothyrotomy)
1. See Advanced Airway for general indications
2. Absolute indications for Advanced Airway
  1. Decreased mental status
  2. Expanding Hematoma
  3. Tracheolaryngeal injury (Tracheal Tear, Laryngeal Fracture)
  4. Hypoxia
  5. Hypoventilation
3. Additional indications to consider for Advanced Airway
  1. Interhospital transfer
  2. Risk of progressive airway compromise
    1. Early Advanced Airway placement is preferred if risk of progression
4. Technique
  1. Rapid Sequence Intubation
  2. Video Laryngoscopy or Fiberoptic intubation over bronchoscope if available
  3. Consider double set-up for immediate Cricothyrotomy as a backup plan
  4. Use slightly smaller Endotracheal Tube than typically used (e.g. decrease by 1/2 size)
  5. Exposed trachea may be intubated directly over a bougie
  6. Avoid blind techniques (risk of exacerbating airway injury)
    1. Avoid Extraglottic Devices (e.g. LMA, Combitube)
    2. Avoid Nasotracheal Intubation

References

(2008) ATLS Manual, American College of Surgeons
Birnbaumer in Herbert (2012) EM:Rap 12(10): 9-11
Cowling and Bernard (2024) Crit Dec Emerg Med 38(2): 4-10
Inaba and Spangler in Herbert (2016) EM:Rap 16(11): 5
Inaba and Herbert in Hebert (2013) EM:Rap 13(3): 7
Swaminathan and Hicks in Herbert (2019) EM:Rap 19(1): 12-3, 15-6