Trauma and Critical Care—Penetrating Neck Trauma
Concept
Mortality as high as 10% with many important structures in close proximity. Systematic evaluation necessary and should include evaluation of potential injuries to airway, esophagus, and vascular system. Classically, broken down into three zones:
(I) clavicles to cricoid cartilage
(proximal carotid, subclavian, vertebrals, esopha- gus, trachea, brachial plexus, spinal cord, tho- racic duct, and upper lung)
(II) cricoid to angle of mandible
(carotid, vertebral, jugular, larynx, esophagus, trachea, vagus, recurrent laryngeal, spinal cord)
(III) angle of mandible to base of skull
(pharynx, distal carotid, vertebrals, parotid, cra- nial nerves)
Way Question May Be Asked?
“You are called to the ED to evaluate a 26 y/o male who was involved in a bar fight and sustained a stab wound to his left neck. On exam, he has a 1 cm laceration at the level of his thyroid cartilage just anterior to his left SCM. What do you want to do?” Presentation may vary and don’t expect much time wasted on differentiating between Zone I-III. May be given an injury to esophagus, carotid, tra- chea, . . . or some combination and asked how you will manage. Be sure to secure the airway early!
How to Answer?
Your history and physical exam come second here to basic ATLS, key points:
Airway Management—endotracheal intubation if any doubt
Hemorrhage—external pressure
Control C-spine if any concern about injury Secondary survey in stable pts to include:
History
Mechanism of injury Size of weapon Amount of bleeding Change in neurologic status Stridor
Physical Exam
Hematoma Bruit Crepitance Hemoptysis Hoarseness
Bubbling from wound
Loss of pulses in upper extremity Horner’s syndrome
Diagnostic Tests (Stable Patients Only)
Laryngoscopy/Bronchoscopy—to assess for airway injuries
Lateral C-spine—SQ emphysema, tracheal deviation CXR—widened or pneumo-mediastinum, pneumotho-
rax, hemothorax, tracheal deviation
Gastrografin swallow—assess esophageal injuries Angiography—All Zone I and Zone III injuries
Surgical Treatment
(1) Management of the airway—
(a) intubate any pt with difficulty in respiration, depressed level of consciousness, expanding hematoma
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(b) careful of cricothyroidotomy as it may release an underlying hematoma
(c) if tracheal injury, can place ETT directly through wound into trachea
(d) watch for tension pneumothorax that might compromise respiration and need urgent decompression
(2) Hemorrhage—
(a) usually controlled by direct pressure (b) avoid blindly applying hemostats
(c) if pulsatile or rapidly expanding, intubate, and go to OR
(d) do not probe the wound!
(3) Zone I (CXR very important!) (a) stable—work-up as outlined above (b) unstable—OR for urgent exploration
(i) sternotomy to obtain proximal control for everything except injury to left of left midclavicular line (then left anterolateral tho- racotomy)
(ii) right subclavian median sternotomy (iii) inominant artery
median sternotomy (iv) left subclavian
trap door incision (4) Zone II
(a) explore anything that penetrates the platysma (b) prep earlobe to umbilicus and upper thigh for
possible SVG harvest (c) anterior SCM incision
(i) esophageal injuries
If < 24 h, repair injury in 2 layers if early If > 24 h, T-tube drainage to create controlled
fistula or Esophagostomy (ii) tracheal injuries
Repair primarily with 3’0 vicryl Tracheostomy if severe injury (iii) thoracic duct
Injury may occur in Zone I or II Ligation acceptable
(iv) jugular vein Repair if possible
Can ligate unilaterally only Watch for air embolism
(v) carotid injury—
Repair even if comatose as this may be secondary to drugs or shock
Ligate if unstable or other life-threatening injuries
Ligate sup. thyroid and repair carotid end to end for small defects, interpose SVG for defects longer than 2 cm
Can reach high carotid artery by:
anterior subluxation of mandible division of omohyoid/digastric
using Fogarty balloon to control proximal bleeding
Common Curveballs
Combined injuries to multiple structures in neck Tension pneumothorax at presentation or after intuba-
tion
Trans-cervical injury (collar incision unless above thy- roid cartilage)
Multiple GSW with abdominal, chest, and neck injuries—what are your priorities?
Thoracic duct injury becomes apparent several days post-op
Questions regarding for which injuries median ster- notomy vs. anterolateral thoracotomy vs. trap-door incisions
Carotid injury in comatose patient
Tissue loss and circumferential carotid injury
Strikeouts
Not securing the airway
Removing impaled foreign body in ED/Trauma Bay Not evaluating for tracheobroncheal or esophageal
injuries
Not performing angiography for Zone I or III injuries Discussing use of U/S instead of angiography
Performing endoscopy before of gastrografin swallow for esophageal injuries
Probing neck wounds in Trauma Bay
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