Penetrating neck trauma: Difference between revisions

Revision as of 07:27, 5 April 2011

Background

Defined by platysma violation
Multiple structures are injured in 30%
- Stab wound can enter in one zone and damage another
Surgery required in 15-20%
Missed esophageal injury is leading cause of delayed death

Zones

Zone 1: Clavicles to inf aspect of cricoid cartilage
- Highest mortality (usually due to exsanguination)
Zone 2: Inf cricoid cartilage to angle of mandible
- Most commonly injuried
Zone 3: Angle of mandible to base of skull

Anatomical Structures at Risk:
- Blood vessels
  - Carotid and vertebral arteries
  - Brachiocephalic and subclavian vessels
  - Jugular vein
Lung apices
Spinal cord
Thoracic duct
Brachial plexus
Phrenic and vagus nerves
Esophagus
- Dysphagia, hematemesis, blood in saliva
Trachea
CN 9-12

Management

Airway
- Consider intubation in:
  - Stridor
  - Hemoptysis
  - Subq emphysema
  - Expanding hematoma
  - Stridor
Breathing
- Minimize BVM (positive pressure > air into soft tissue plains)
Circulation
- Place IV on contralateral side of injury

Imaging
- CT and CTA
  - Useful for evaluating esophageal injury
- Angiography
  - Useful if embolization or stent placement are anticipated

Authors:

@@ Line 1: / Line 1: @@
 __TOC__
 ==Background==
+*Defined by platysma violation
-*Accounts for 5-10% of traumatic injuries in adults
+*Multiple structures are injured in 30%
-*Multiple structures are injured in 30% (especially if breach in platysma)
+**Stab wound can enter in one zone and damage another
+*Surgery required in 15-20%
+*Missed esophageal injury is leading cause of delayed death
 ==Zones==
-*Zone 1: Between clavicles and inf aspect of cricoid cartilage
+*Zone 1: Clavicles to inf aspect of cricoid cartilage
-*Zone 2: From cricoid cartilage superiorly to the angle of the mandible
+**Highest mortality (usually due to exsanguination)
+*Zone 2: Inf cricoid cartilage to angle of mandible
+**Most commonly injuried
 *Zone 3: Angle of mandible to base of skull
 *Anatomical Structures at Risk:
-*carotid (common, internal external)
+**Blood vessels
-*vertebral arteries
+***Carotid and vertebral arteries
-*subclavian vessels
+***Brachiocephalic and subclavian vessels
-*jugular vein
+***Jugular vein
-*brachiocephalic vein
+*Lung apices
-*aortic arch
+*Spinal cord
-*lung apices
+*Thoracic duct
-*cervical spine/cord
+*Brachial plexus
-*thoracic duct
+*Phrenic and vagus nerves
-*brachial plexus
+*Esophagus
-*phrenic nerve
+**Dysphagia, hematemesis, blood in saliva
-*vagus nerve
+*Trachea
-*recurrent laryngeal nerve
+*CN 9-12
-*esophagus
-*trachea
-*larynx
-*partoid/salivary glands
-*cranial nerves 9-12
-*floor of mouth/skull
 ==Management==
 *Airway
-**Consider early airway stabilization esp in those with respiratory distress, subq emphysema, expanding hematoma, AMS, or in those with direct laryngotracheal trauma
+**Consider intubation in:
+***Stridor
-- RSI  has been proven safe and effective
+***Hemoptysis
+***Subq emphysema
-- minimize BVM as positive pressure generated can cause air to dissect into the neck and worsen injuries
+***Expanding hematoma
+***Stridor
-- Orotracheal intubation usually successful but always have backup plan (fiberoptic, nasal intubation, surgical airway)
+*Breathing
+**Minimize BVM (positive pressure > air into soft tissue plains)
+*Circulation
+**Place IV on contralateral side of injury
-Surgical Management
-Immediate Exploration if:
-- hard signs of vascular injury (expanding hematoma, severe active/pulsatile bleeding, bruit, palpable thrill)
-- HD unstable
-- airway compromise
-Can delay surgical management for further evaluation/imaging if not
-Imaging/Other studies
-Plain Films
-- not helpful in visualizing soft tissues/vacular structures
-- can show foreign bodies, fractures, tracheal displacement, hemo/penumothorax, widened mediastinum, apical hematoma, etc
-Angiography
-- gold standard for evaluating vasculature
-- more important for Zone 1 and 3 injuries, especially for surgical planning
-CT Angio
-- shows soft tissue, bone, and vascular injury
-- similar results as traditional angiography
-- if normal, may consider eliminating surgical exploration in zone 2 PNI in a HD stable patient
-Bronchoscopy
-Esophagraphy/Esophagoscopy
+*Imaging
+**CT and CTA
+***Useful for evaluating esophageal injury
+**Angiography
+***Useful if embolization or stent placement are anticipated
 [[Category:Trauma]]