Penetrating and Blunt Neck Trauma Tintinalli Chapter 258

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Penetrating and Blunt Neck TraumaTintinalli
Chapter 258
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Anatomy

• Complex network of neurovasuclar muscular
  structures supported by various fascial planes
• Two methods used to describe the neck Zones
  Triangles
• Anterior Triangle anteriorly by the midline
  posteriorly by the SCM superiorly by the
  mandible
• Posterior Triangle anteriorly by the SCM
  inferiorly by the clavicle posteriorly by the
  anterior border of the trapezius muscle

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Anatomy

• Anterior Triangle Structures carotid artery,
  internal jugular vein, vagus nerve, thyroid
  gland, larynx, trachea, and esophagus
• Posterior Triangle Structures few vital
  structures, except at its base, where the
  subclavian artery and brachial plexus are located

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Anatomy

• Zones
• One superiorly from the sternal notch
  clavicles to the cricoid cartilage (injury
  affects both neck mediastinal structures)
• Two cricoid cartilage to the angle of the
  mandible
• Three angle of the mandible to the base of the
  skull

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Anatomy

• Zone I includes the vertebral and proximal
  carotid arteries, major thoracic vessels,
  superior mediastinum, lungs, esophagus, trachea,
  thoracic duct, and spinal cord
• Zone II involve the carotid and vertebral
  arteries, jugular veins, esophagus, trachea,
  larynx, and spinal cord
• Zone III includes the distal carotid and
  vertebral arteries, pharynx, and spinal cord

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Anatomy

• Fascial Planes
• Platysma thin muscle covers the entire anterior
  triangle and the anteroinferior aspect of the
  posterior triangle serves as an important planar
  landmark when evaluating penetrating neck
  injuries
• Deep Cervical Fascia invest deep structures
  important due to the pretracheal deep fascias
  communication to the anterior mediastinum (neck
  trauma can lead to mediastinitis)

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Initial Management

• ABCs
• Always be ready for a cricothyroidotomy
• Maintain C Spine alignment until cleared via
  Nexus (if you believe in it) or imaging or BOTH
• Direct pressure for bleeding
• Disability try to assess quickly if intubation

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Signs and Symptoms

• Hard (trauma more likely)
• Hypotension in the ED
• Active Arterial Bleeding
• Diminished Carotid Pulse
• Expanding Hematoma
• Bruit
• Lateralizing Signs
• Hemothroax gt 1000 mL
• Air Bubbling Wound
• Hemoptysis
• Hematemesis

• Soft
• Hypotension in the field
• HX of Arterial bleeding
• Tracheal deviation
• Large hematoma
• Stridor
• Hoarseness
• Vocal cord paralysis
• Sub Q Air
• 7th cranial nerve injury
• Unexplained bradycardia

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Diagnostic Strategies

• Prospective study of 393 patients with
  penetrating neck injuries found 30 of patients
  with no physical findings had positive findings
  on surgical exploration.
• Another study of 223 patients found physical
  examination was reliable to determine which
  patients needed vascular or esophageal studies.
• However, if hard signs present, then evaluation
  should continue

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Mechanism of Injury

• Penetrating Injuries
• Blunt Injuries
• Strangulation

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Penetrating Injury

• Is the platysma penetrated?
• Stable vs. Unstable
• Stable
• Zone I injures should undergo angiography and
  esophagram and/or esophagoscopy
• Zone III injures should undergo angiography and
  thoracic consultation
• Zone II undergo mandatory exploration or be
  evaluated with angiography and esophagram and/or
  esophagoscopy
• Patients with laryngotracheal symptoms require
  laryngoscopy bronchoscopy
• Helical CT Angiogram is an option for stable
  patients, but sensitivity not as good for zone I
  III injury patterns

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Evaluation Plan
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Blunt Injury

• Much more rare
• Symptoms may be minimal or delayed
• Classic symptoms include dysphonia, hoarseness,
  dysphagia, odynophagia, dyspnea, pain,
  hemoptysis, and stridor
• Laryngoscopy and bronchoscopy - vocal cord
  function, luminal integrity, and level of injury
• Esophagram esophagoscopy if significant injury
  found to other structures or high clinical
  suspicion
• Causes 3-10 of all cervical vascular injury
• Two patterns - pseudo-aneurysm or dissection can
  occur (new bruit or neurologic symptoms)

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Strangulation

• Severe Hoarseness stridor are suggestive of
  impending airway obstruction
• Death from three Mechanisms
• Injury to the spinal cord or brain stem
• Mechanical constriction of the neck structures
• Cardiac Arrest

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Strangulation Treatment

• C spine injury is rare unless significant drop
  during strangulation
• Neurogenic pulmonary edema best prevented with
  PEEP
• Cardiac monitoring essential to follow possible
  dysrhythmias
• Watch for increased ICP (Cushings)

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Pearls

• Exsanguination is the leading cause of immediate
  death
• Esophageal injury is the leading cause of delayed
  death
• Neck wounds should never be probed can lead to
  massive hemorrhage or air embolus
• Cervical Collars can obscure significant injury
• Vascular injury from blunt trauma is difficult to
  identify
• Transcervical gunshot wounds have a high
  incidence of visceral-vascular injury
• All near-hanging or strangulation patients who
  are comatose or AMS may have elevated ICP

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Reference

• Tintinalli Chapter 258
• Rosens Chapter 41