Penetrating neck trauma: Difference between revisions
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==Background== | |||
*Accounts for 5-10% of traumatic injuries in adults | |||
*Multiple structures are injured in 30% (especially if breach in platysma) | |||
==Zones== | |||
*Zone 1: Between clavicles and inf aspect of cricoid cartilage | |||
*Zone 2: From cricoid cartilage superiorly to the angle of the mandible | |||
*Zone 3: Angle of mandible to base of skull | |||
Revision as of 23:42, 2 April 2011
Background
- Accounts for 5-10% of traumatic injuries in adults
- Multiple structures are injured in 30% (especially if breach in platysma)
Zones
- Zone 1: Between clavicles and inf aspect of cricoid cartilage
- Zone 2: From cricoid cartilage superiorly to the angle of the mandible
- Zone 3: Angle of mandible to base of skull
Anatomical Structures at Risk:
- carotid (common, internal external)
- vertebral arteries
- subclavian vessels
- jugular vein
- brachiocephalic vein
- aortic arch
- lung apices
- cervical spine/cord
- thoracic duct
- brachial plexus
- phrenic nerve
- vagus nerve
- recurrent laryngeal nerve
- esophagus
- trachea
- larynx
- partoid/salivary glands
- cranial nerves 9-12
- floor of mouth/skull
Management
Airway
- consider early airway stabilization especially in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
- RSI has been proven safe and effective
- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
Surgical Management
Immediate Exploration if:
- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)
- HD unstable
- airway compromise
Can delay surgical management for further evaluation/imaging if not
Imaging/Other studies
Plain Films
- not helpful in visualizing soft tissues/vacular structures
- can show foreign bodies, fractures, tracheal displacement, hemo/penumothorax, widened mediastinum, apical hematoma, etc
Angiography
- gold standard for evaluating vasculature
- more important for Zone 1 and 3 injuries, especially for surgical planning
CT Angio
- shows soft tissue, bone, and vascular injury
- similar results as traditional angiography
- if normal, may consider eliminating surgical exploration in zone 2 PNI in a HD stable patient
Bronchoscopy
Esophagraphy/Esophagoscopy