Penetrating Neck Trauma
20 PENETRATING NECK TRAUMA
Clay Cothren M.D., Ernest E. Moore M.D.
1. Why are penetrating neck wounds unique?
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Although comprising only a small percentage of body surface area, the neck contains a heavy concentration of vital structures.
2. What constitutes a penetrating neck wound?
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Violation of the platysma muscle defines a penetrating neck wound. This investing fascial layer of the neck is superficial to vital structures. If the platysma is not penetrated, the wound is managed as a simple laceration.
3. Identify the boundaries of the three zones of the neck.
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Zone I extends from the sternal notch to the cricoid cartilage.
Zone II extends from the cricoid cartilage to the angle of the mandible.
Zone III comprises the area cephalad to the angle of the mandible.
These zones have distinct management implications.
4. Which side of the neck is more likely to be injured?
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The left side because most assailants are right-handed.
5. Do gunshot wounds and knife wounds cause the same relative injuries?
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Gunshot wounds generally tend to inflict more tissue damage (see Table 20-1).
Table 20-1. GUNSHOT VERSUS TAB WOUNDS
|
Structure
|
Gunshot Wounds
|
Stab Wounds
|
|
Artery
|
20%
|
5%
|
|
Vein
|
15%
|
10%
|
|
Airway
|
10%
|
5%
|
|
Digestive
|
20%
|
< 5%
|
6. What are the priorities in the management of penetrating neck trauma?
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The ABCs (airway, breathing, and circulation) are the first priority in every trauma patient. Patients should be intubated orally, although cricothyrotomy may be necessary with an extensive neck wound. Although the patient may present with a patent airway, early elective airway control is advisable in patients with expanding hematomas. Pneumothoraces or hemothoraces may be associated with these injuries depending on the trajectory. While hemorrhage is being controlled with direct pressure, IV access is secured with two large-bore peripheral lines.
7. How should bleeding be controlled at the accident scene and in the emergency department?
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Direct pressure is nearly always successful, even for major arterial lesions. Do not blindly place clamps because the risk of injury to vital structures is high.
8. Should you explore the wound in the trauma bay?
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Only if the patient is asymptomatic and there has been no evidence of hemorrhage. Probing the wound may dislodge a clot, causing marked hemorrhage.
9. What physical signs are consistent with significant injury?
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Ongoing hemorrhage from the wound, expanding or pulsatile hematoma, hemoptysis, hematemesis, neurologic deficits, dysphagia, dysphonia, hoarseness, and stridor mandate an early trip to the operating room.
10. How often do patients with crepitus (in the neck) have a significant injury?
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One third of patients with crepitus have an injury of the pharynx, esophagus, larynx, or trachea. In two thirds of these patients, however, the air has been introduced through the wound entrance site, and there is no significant underlying injury.
11. What is selective management of penetrating neck trauma?
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Previously, operative exploration was advocated for all zone II injuries violating the platysma; this approach has lost support. With 50% of penetrating neck wounds not associated with significant injury, exploration is not mandatory. Alert and asymptomatic patients are evaluated with a combination of diagnostic studies (see later) or are observed expectantly with frequent serial physical examinations.
KEY POINTS: SELECTIVE MANAGEMENT OF PENETRATING INJURIES TO ZONE II
1. Penetrating injury implies violation of the platysma.
2. Mandatory exploration of all zone II injuries is not necessary since 50% of wounds are not associated with significant injury.
3. Alert and asymptomatic patients should be observed expectantly for at least 24 hours.
4. Symptomatic patients (exsanguinations or expanding hematoma) proceed to the operating room for exploration.
5. Aerodigestive symptoms (e.g., stridor, dysphonia) mandate further diagnostic testing: laryngoscopy, bronchoscopy, and esophagram.
12. Should arteriography be performed on all patients?
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Preoperative arteriograms generally are performed in hemodynamically stable patients with zone I injuries. Their value is to identify injuries to major vessels in the thoracic outlet that may require a thoracic operative approach. Wounds in zone III are treated best by angioembolization if there is evidence of significant bleeding.
13. What is the value of other diagnostic studies, such as esophagography, esophagoscopy, laryngoscopy, and bronchoscopy?
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Routine use of esophagography, bronchoscopy, and laryngoscopy has been advocated in zone I and selected nonoperatively managed zone II patients. Esophagoscopy is combined with esophagography if esophageal injury is suspected; if water-soluble contrast material does not show a leak, barium is used. Missed esophageal injuries can be deadly, with a 20% mortality rate if diagnosis is delayed only 12 hours. Angiography remains the gold standard for diagnosis of arterial injury, and this modality may be therapeutic for zone III injuries (zone III is tough to expose surgically). Intraoperative endoscopy with insufflation may be used provocatively to show an air leak and associated esophageal injury.
14. What is the role of CT?
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If patients have a high-risk trajectory (i.e., transcervical gunshot wounds), CT may identify the “line of fire” and help determine the need for angiography (see Figure 20-1).
Figure 20-1 Management of penetrating neck trauma.
15. Should an asymptomatic patient with a penetrating neck wound be sent home from the emergency department?
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No. Life-threatening penetrating neck wounds initially may be difficult to sort out; the safest policy is to observe all patients in the hospital for at least 24 hours.
References
WEB SITES
1. http://www.acssurgery.com/abstracts/acs/acs0504.htm
2. http://www.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/penetrneck.htm
BIBLIOGRAPHY
1. Albuquerque FC, Javedan SP, McDougall CG: Endovascular management of penetrating vertebral artery injuries. J Trauma 53:574-580, 2002. Medline Similar articles Full article
2. Atteberry LR, Dennis JW, Menawat SS, Frykberg ER: Physical examination alone is safe and accurate for evaluation of vascular injuries in penetrating zone II neck trauma. J Am Coll Surg 179:657-662, 1994. Medline Similar articles
3. Biffl WL, Moore EE, Rehse DH, et al: Selective management of penetrating neck trauma based on cervical level of injury. Am J Surg 174:678-682, 1997. Medline Similar articles Full article
4. Demetriades D, Velmahos G, Asensio JA: Cervical pharygoesophageal and laryngotracheal injuries. World J Surg 25:1044-1048, 2001. Medline Similar articles Full article
5. Gracias VH, Reilly PM, Philpott J, et al: Computed tomography in the evaluation of penetrating neck trauma: A preliminary study. Arch Surg 136:1231-1235, 2001. Medline Similar articles Full article
6. Hirshberg A, Wall MJ, Johnston RH, et al: Transcervical gunshot injuries. Am J Surg 167:309, 1993.
7. Mazolewski PJ, Curry JD, Browder T, Fildes J: Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J Trauma 51:315-319, 2001.
8. McIntyre WB, Blaard JL: Cervicothoracic vascular injuries. Semin Vasc Surg 11:232-242, 1998. Medline Similar articles
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
