Penetrating Neck Injury

Overview

• GSW more likely than stab wound to cause vascular and aerodigestive injury
  • Vascular injury 
    • Most common cervical injury
    • Most common cause of death in penetrating neck trauma
    • Carotid is the most common structure involved 
• Zones

• Zone II is the most commonly injured area
• Zone I injuries have the highest mortality rate
• Mortality = 20% for laryngotracheal trauma

Evaluation

• Hard Signs of Vascular Injury 
  • Severe/Uncontrolled hemorrhage
  • Large, expanding, or pulsatile hematoma
  • Thrills/Bruits
  • Shock unresponsive to IVF
  • Absent or diminished radial pulse
  • Neuro deficits c/w cerebral ischemia 
• Hard Signs of Aerodigestive Injury
  • Air bubbling from wound
  • Massive hemoptysis/hematemesis
  • Respiratory distress
• Soft Signs
  • Proximity wounds (1-2 cm of a major vessel)
  • Minor Hemorrhage
  • Mild hypotension responsive to IVF
  • SubQ or mediastinal air (questionable as to whether this should be a hard sign if significant)
  • Hematoma (nonpulsatile, not expanding)
  • Dysphonia 
  • Dysphagia
• Ultrasound/CXR
  • Use in Zone I injuries to evaluate for PTX
• CTA Neck
  • Can do in stable patients
  • 100% Sn, 97.5% Sp for detecting significant vascular or aerodigestive injury
  • Limited in detecting pharyngoesophageal injuries
  • Allows of evaluation of trajectory

Management

• C-spine immobilization only necessary when neuro deficit is present or proper examination cannot be performed
• Airway
  • Require intubation
    • Respiratory distress
    • Severe hemorrhage
    • Extensive or sucking neck wound
    • Shock
  • Consider Intubation
    • Significant bleeding or neck hematoma
    • Hemoptysis
    • Subcutaneous neck emphysema
    • Bruit or thrill
    • Distorted neck anatomy
    • Stridor
    • Difficulty or pain when swallowing secretions
    • Abnormal voice, especially hoarseness (“hot potato voice”)
  • Fiberoptic Laryngoscopy
    • In stable patients, fiberoptic laryngoscopy able to evaluate integrity of airway above and below chords with Ambuscope
    • Consider intubation if e/o direct airway injury
  • Prepare double set-up lest orotracheal intubation is unsuccessful
• Unstable penetrating neck injuries go directly to OR
• EAST guidelines accept both mandatory surgery and selective management for Zone II injuries
• Stable patients with hard signs and violation of the platysma should go to the OR
• Stable patients with only soft signs and violation of the platysma should undergo CTA Neck
• Stable patients without symptoms may be observed or undergo CTA Neck