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Clinical Hub,References,Level I Adult Trauma Center Manual,Head and Neck

Management of Penetrating Neck Injury

Management of Penetrating Neck Injury - Clinical Hub, References, Level I Adult Trauma Center Manual, Head and Neck

Focus

Objective

To provide guidelines for the management of a penetrating injury to the neck, specifically as it relates to the operative exploration and the ordering of diagnostic studies.

Definitions

Penetrating Injury: Any inflicted injury that penetrates the skin. This could be a gunshot wound, stab wound or foreign body penetration of any nature. These guidelines do not apply to penetration of the oral or pharyngeal mucosa as might be seen with medical instruments, etc.

Neck: The circumferential region of the body bounded by the clavicles and the base of the skull.

Guidelines

  1. For all penetrating injuries of the neck, first apply all of the principals of ATLS, Pay particular attention to the airway, since this will be the most life-threatening associated condition. Emergency crycothyrotomy should be avoided in the Emergency Department, if possible, since a contained hematoma can be released with disastrous consequences. Remember that neck injuries can be associated with chest injuries; therefore, chest assessment should be fully undertaken.
  2. If the neck injury is associated with any of the following conditions, then the patient should be taken immediately to the operating room for exploration
    1. Shock
    2. Active hemorrhage – the surgeon should attempt to tamponade the bleeding, such as with direct pressure or a catheter, while en route to the OR
    3. Expanding hematoma
    4. Need for surgical airway
    5. Obvious esophageal injury
    6. Obvious tracheal injury
  3. For other stable neck injuries, a determination should be made as to whether the platysma has been penetrated. Slash wound wounds can easily be examined to determine this. Usually slash wounds can be fully explored and closed in the ED if there are no major injuries. For puncture wounds that seem superficial, the wound can be anesthetized and enlarged for a direct visual observation to determine if the platysma is intact. Do not probe neck wounds. If the platysma is intact, then close the wound if possible and discharge.
  4. If the platysma has been violated, then classify the wound as:
    1. Zone I – below cricoid cartilage
    2. Zone II – between cricoid and angle of the mandible
    3. Zone III – above the angle of the mandible
    4. An X-ray of the neck may be helpful if a bullet or foreign body is still in the neck and to assess for subcutaneous air.
  5. For Zone 1 injuries:
    1. Obtain a chest X-ray to determine the presence of chest injury.
    2. Obtain CT scan to determine the track of bullet
    3. If track approaches vessels or airway, angiogram
    4. May require a median sternotomy with extension to an anterior sternocleidomastoid incision or supraclavicular incision with or without clavicular head resection
    5. Hemodynamically stable patients with CTA evidence of Zone 1 injury (vascular or aerodigestive) typically require prompt additional intervention (operative or endovascular procedures). Patients without CTA documented aerodigestive injury but with a concerning trajectory should undergo further evaluation with esophagoscopy or esophagography and bronchoscopy
  6. For Zone 2 injury, use clinical findings to classify as low probability of vascular and aerodigestive injury or high probability of vascular and aerodigestive injury.
    1. For high probability injuries (GSW, swelling, path crossing midline):
      1. If the injury is a gunshot wound, consider an angiogram to help define extent and location of vascular injury if the patient is stable.
      2. Prophylaxis with antibiotics
      3. Take to the operating room for neck exploration
        1. Transcervical zone 2 injuries may be explored through a collar incision
    2. For low probability injuries (stab wounds, minimal swelling, lateral, posterior). Obtain CT scan and look for injuries to vital structures. If found:
      1. Obtain angiogram or CTA
      2. Obtain esophagram
      3. Perform laryngoscopy and bronchoscopy if indicated (air in tissues or subcutaneous emphysema)
      4. Treat based on findings
    3. Hemodynamically stable patients with Zone 2 wounds and symptoms (dysphagia, voice change, hemoptysis, hematemesis, and/or bruit/thrill) should undergo operative neck exploration. Patients with concerning trajectory should undergo further evaluation with esophagoscopy or esophogography and bronchoscopy.
  7. For Zone 3 Injuries
    1. Obtain angiogram
    2. Obtain or perform direct pharyngoscopy and laryngoscopy
    3. Treat based on findings
      1. May require subluxation, dislocation, or resection of the mandible to obtain vascular control
      2. Hemodynamically stable patients with Zone 3 arterial and aerodigestive injuries on CTA often require further interventions (embolization or covered stenting based upon the location of injury and/or repair of pharyngeal penetrating injuries).
  8. For GSW injuries (usually Zone 2) that appear to have traversed the neck lateral to the carotid sheath, a CT scan (with contrast) can define the bullet track. The proximity to the vessels and aerodigestive organs can be determined as an indicator for any additional studies.
  9. For all penetrating neck injuries that have violated oral mucosa, treat with antibiotics
  10. Contrast swallow studies are less sensitive in detecting hypopharyngeal injuries as compared with esophageal injury and flexible nasoedoscopy or video endoscopy should be part of the surgeon’s armamentarium.

1. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. The journal of trauma and acute care surgery. Dec 2013; 75 (6): 936-940

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