Penetrating neck trauma

Background

Zones of Neck

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

• Defined by platysma violation
  • Assume significant injury has occurred until proven otherwise
  • Never probe neck wounds beneath the platysma (may disrupt hemostasis)
• Multiple structures are injured in 50%
  • Stab wound can enter in one zone and damage another
• Missed esophageal injury is leading cause of delayed death
• GSW that crosses midline of 2x as likely to cause injuries to vital structures
• Blunt cervical vascular injury should be treated with systemic anticoagulation
• Penetrating injury rarely results in unstable fracture

Injuries Patterns by Zone

• These patterns are neither sensitive nor specific
  • Neck zones were classically used to determine workup. However, evaluation has moved primarily to a "zoneless" approach in part due to easy access to neck CTA.

Zone	Anatomic Landmarks	Potential Injuries
1	Clavicle to cricoid	subclavian artery and vein jugular vein common carotid artery trachea thryroid esophagus apex of the lung
2	Cricoid to angle of mandible	carotid arteries internal jugular vein esophagus larynx cranial nerves X, XI, and XII spine
3	Angle of mandible to base of skull	lateral pharynx cranial nerves VII, IX, X, XI, and XII spine carotids

Clinical Features

Hard vs. Soft Neck Signs

Hard Signs	Soft Signs
Airway compromise	Subcutaneous emphysema
Air bubbling wound	Dysphagia, dyspnea
Expanding or pulsatile hematoma	Non-pulsatile, non-expanding hematoma
Active Bleeding	Venous oozing
Shock, compromised radial pulse	Chest tube air leak
Hematemesis	Minor hematemesis
Neuro Deficit/Paralysis/Cerebral ischemia	Paresthesias
Absent or unequal radial pulse

Differential Diagnosis

Neck Trauma

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical fractures and dislocations
  • Cervical injury (peds)
  • Cervical spine clearance
• Neurogenic shock
• Spinal cord injury

Evaluation

Algorithm for CTA Neck after penetrating trauma]

Workup (WTA Algorithm)

• If hard signs or hemodynamic instability, attempt tamponade, secure airway, then directly to OR for surgical exploration
• If no hard signs and yet suspect injury, CTA neck with IV contrast

Management

General

• Airway
  • If integrity of larynx is in question trach may be safer than intubation
  • One attempt at intubation by most experienced provider with tube one size smaller
    • If failure, surgical airway should be performed
    • Emergency tracheostomy preferred to cricothyrotomy
  • Consider intubation if:
    • Stridor
    • Hemoptysis
    • Subcutaneous emphysema
    • Expanding hematoma
• Breathing
  • Minimize BVM (positive pressure --> air into soft tissue plains)
  • Consider ultrasound or CXR to eval for PTX, especially if Zone I injury
• Circulation
  • Place IV on contralateral side of injury
• Disability
  • Neuro deficits may be secondary to direct cord injury or cerebral ischemia secondary to carotid injury
  • Place in C-collar only if:
    • ALOC, neuro deficits, or significant blunt injury

By Zone

Zone I

• Portable CXR
• Evaluation is generally by selective, nonoperative management
• Vascular control can be difficult; requires thoracic surgical approach

Zone II

• Optimal management is controversial
  • Platysma penetration
    • No penetration → Observe, possible discharge
    • Penetration + Vitals/Airway stable → CTA of neck
    • Penetration + Vitals/Airway unstable, or other hard signs → OR for surgical exploration
• All bleeding should be controlled with pressure, not with clamps

Zone III

• Treat as cranial injuries
• Evaluation is generally by selective, nonoperative management
  • Routine exploration of zone III is not indicated

By Structure

Esophagus

• Injuries are often initially asymptomatic
  • If missed can lead to neck space infection, mediastinitis
• Esophagoscopy or contrast esophagography indicated if:
  • CT is equivocal or abnormal
  • Missile trajectory places esophagus at risk for injury
  • Persistent symptoms

Laryngotracheal

• Suspect if:
  • Air bubbling through wound
  • Dyspnea, stridor
  • Hemoptysis
  • Subcutaneous emphysema
• Laryngoscopy is indicated if:
  • Suspect laryngotracheal injury even if CT is negative

Disposition

• If neck CT with contrast is negative, may observe patient

See Also

• Spinal cord trauma
• Blunt neck trauma
• Head trauma (main)