View source for Penetrating neck trauma

== Background ==
[[File:Cta-neck-trauma-algorithm.png|thumb|Algorithm for CTA Neck after penetrating trauma]<ref>Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936–940. [http://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsPenetratingNeckTrauma.pdf|fulltext] </ref>]]
*Defined by platysma violation
**Assume significant injury has occurred until proven otherwise 
**Never probe neck wounds beneath the platysma (may disrupt hemostasis)
*Multiple structures are injured in 50% 
**Stab wound can enter in one zone and damage another 
*Missed esophageal injury is leading cause of delayed death
*GSW that crosses midline of 2x as likely to cause injuries to vital structures
*Blunt cervical vascular injury should be treated w/ systemic anticoagulation

===Zones of Neck===
{| class="wikitable sortable"
|+Injuries Patterns by Zone
!Zone!!class="unsortable"|Anatomic Landmarks!!class="unsortable"|Potential Injuries
|-
| 1||clavicle to cricoid||
#subclavian artery and vein
#jugular vein
#common carotid artery
#trachea,
#thryroid
#esophagus
#apex of the lung
|-
| 2||cricoid to angle of mandible||
#carotid arteries
#internal jugular vein
#esophagus
#larynx
#cranial nerves X, XI, and XII
#spine
|-
| 3||angle of mandible to base of skull||
#lateral pharynx
#cranial nerves VII, IX, X, XI, and XII
#spine
#carotids
|}

== WTA Algorithm ==
=== Hard Signs ===
*If hard signs or HD instability, attempt tamponade, secure airway, then OR.
*If no hard signs and yet suspect injury, CTA.

{| class="wikitable sortable"
|+ Hard vs. Soft Neck Signs
|-
! scope="col" | '''Hard Signs'''
! scope="col" | '''Soft Signs'''

|-
| Airway compromise ||Subcutaneous emphysema
|-
| Air bubbling wound|| 
|-
| Expanding or pulsatile hematoma||Non-pulsatile, non-expanding hematoma
|-
| Active Bleeding||Venous oozing
|-
| Shock ||Subcutaneous emphysema
|-
| Hematemesis ||Minor hematemesis
|-
| Neuro Deficit/Paralysis ||Paresthesias 
|}

=== Imaging ===
*CXR 
**Pneumo/hemothorax, pneumomediastinum 
**CTA 
***1st line
**Angiography 
***Gold-standard
***Useful if embolization or stent placement are anticipated or CT inconclusive

==Management ==
===General===
*Airway 
**If integrity of larynx is in question trach may be safer than intubation 
**Consider intubation if: 
***Stridor 
***Hemoptysis 
***Subq emphysema 
***Expanding hematoma 
*Breathing 
**Minimize BVM (positive pressure &gt; air into soft tissue plains) 
*Circulation 
**Place IV on contralateral side of injury 
*Disability 
**Neuro deficits may be 2/2 direct cord injury or cerebral ischemia 2/2 carotid injury 
**Place in C-collar if: 
***ALOC, neuro deficits, or sig. blunt injury
===By Zone===
====Zone I====
*Portable CXR
*Evaluation is generally by selective, nonoperative management
*Vascular control can be difficult; requires thoracic surgical approach
====Zone II====
*Optimal management is controversial
**Platysma
***Not penetrated: obs and discharge
***Penetrated and vitals/airway stable: CT angio of neck
***Penetrated and unstable, expanding hematoma: OR
*All bleeding should be controlled with pressure, not with clamps

====Zone III====
*Treat as cranial injuries
*Evaluation is generally by selective, nonoperative management
**Routine exploration of zone III is not indicated
===By Structure===
====Esophagus====
*Injuries are often initially asymptomatic
**If missed can lead to neck space infection, mediastinitis
*Esophagoscopy or contrast esophagography indicated if:
**CT is equivocal or abnormal
**Missile trajectory places esophagus at risk for injury
**Persistent symptoms
====Laryngotracheal====
*Suspect if:
**Air bubbling through wound
**Dyspnea, stridor
**Hemoptysis
**Subcutaneous emphysema
*Laryngoscopy is indicated if:
**Suspect laryngotracheal injury even if CT is negative

===Disposition===
*If CT is negative may observe pt

== See Also ==
{{Head Neck Trauma}}

== Source ==
*Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e (2010), Chapter 257. Trauma to the Neck
*Western Trauma Association critical decisions in trauma (2013)
<references/>

[[Category:ENT]] [[Category:Trauma]]