It has been far too long since we have covered a trauma subject, so today: Penetrating Neck Trauma. The entire approach has changed since I did my first trauma fellowship 20 years ago. Today, we discuss the current management and treatment of penetrating neck trauma.
Review Paper
What sparked my doing this episode was a very nice review paper in J Trauma by Siletz and friend of the show, Kenji Inaba.
Diagnostic approach to penetrating neck trauma [10.1097/TA.0000000000002919]
Signs of Neurovascular Injury
- Hemodynamic instability
- Arterial bleeding
- Expanding, pulsatile hematoma
- Any pulse or neurologic deficit
- Bruit or thrill [bruit means you need a stethoscope]
Signs of Aerodigestive Injury
- Air bubbling
- Extensive Subcutaneous emphysema
- Stridor
- Hematemesis
(J Trauma Acute Care Surg. 2020;89[6]:1233.)
The No Zone Approach [cite source='pubmed']26117413[/cite]
Temporary Hemostasis
Direct Pressure/Packing
Foley Catheter
18 F foley, can use multiple if necessary
- Flush inner lumen with saline
- Place in wound
- Gently inflate
- Can put a purse string around the foley entrance
Written up by Weppner et al. [23823611]
ITClamp
Sort of like a whipstitch but with better tamponade
Airway Management
Sit the patient up, you can even hand the pt a suction cath
Options
Intubate from above
Intubate through the wound
Surgical Airway
Air Embolism
If the patient crashes and burns right after intubation–consider air embo
Cervical Collar
No c-spine protection is needed for penetrating injuries unless a strong suspicion or concomitant blunt trauma
Even in high velocity gunshot wounds the risk of cervical injury that a collar would help is very low [J Trauma 1989;29:332]
Not recommended for civilian penetrating trauma [Barkana et al. 10775682]
Physical Exam
Penetrate Platysma?
Ask patient to swallow their own saliva
Ask them if their voice sounds normal
Ask them to cough
Listen to the carotid
Neck Zones
Zones of the Neck
Zone 1
Clavicle to cricoid
Zone 2
Cricoid to mandible
Zone 3
Above the mandible
Zone 4
Posterior neck injuries
The move to the Zoneless approach
- Zone of entry is not necessarily the zone of injury
- Negative explorations still have morbidity
- Most recent systematic review [Kareem et al 10.1097/TA.0000000000002919]
CTA
Mark the skin entry site
Western Trauma Association Algorithm
Equivocal CTA
Suspicion of Aerodigestive Injury on CT
- Laryngoscopy for Pharyngeal Injuries
- Preop Bronch for Tracheal Injury
- Esophagoscopy and/or Swallow for Esophageal
- First water soluble swallow (iso-oncotic)
- Dispute over the need for barium [10.1136/emj.2008.063958]
- CT Esophogram [10.1148/rg.2021200132], can be performed on a pt that can't cooperate with the swallow tests
Vascular Injuries
- DSA
Hanson's Anatomy Image
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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