Neck Lacerations and Penetrating Injuries



Ovid: 5-Minute Sports Medicine Consult, The


Neck Lacerations and Penetrating Injuries
Neha P. Raukar
Basics
Pediatric Considerations
  • Esophageal and venous injuries present with very subtle findings, and the diagnosis of injuries to these structures is often delayed.
Alert
  • Unstable patients with penetrating neck trauma receive definitive care in the operating room.
  • Stable patients should be transferred to a trauma center.
  • Occlusive dressings that are soaked in petroleum jelly should be applied to lacerations over major veins to prevent air embolism. If possible, patients should also be placed in Trendelenburg.
  • Before attempting to secure the airway, be sure to have a surgical airway kit at the bedside.
  • Do not be fooled by the seemingly stable patient. These patients can decompensate rapidly and without warning.
  • Surgical intervention is required in 15–20% of cases of penetrating neck injury (1).
Description
  • Penetrating neck trauma is defined as a wound that violates the platysma muscle.
  • The neck is divided into 3 zones based on superficial landmarks, and are numbered from most caudal to cephalad:
    • Zone I extends from the top of the sternum to the sternal notch or cricoid cartilage:
      • Penetrating trauma in this zone carries the highest mortality due to injury to thoracic structures.
      • An isolated Horner's syndrome may be the only presenting sign of injury to this zone.
    • Zone II extends from the cricoid cartilage to the angle of the mandible:
      • The majority of penetrating neck wounds occur in this zone.
      • However, since injured structures are more easily identified, treatment, both in the emergency department and the operating room, is more often successful. Therefore, mortality rates are the lowest in this zone.
    • Zone III extends cephalad from the angle of the mandible to the base of the skull:
      • Least commonly injured
      • Injuries to the distal carotid artery can mimic a stroke.
Etiology
  • Gunshot wounds
  • Stab wounds
  • Miscellaneous (glass shards, metal fragments)
  • Sports trauma (cleat spikes, hockey stick laceration, shattered baseball bat fragments, etc.)
Diagnosis
  • Careful examination of the wound to determine integrity of the platysma
  • Wounds should never be blindly probed, as this may result in uncontrolled hemorrhage.
  • Lateral neck radiograph to evaluate soft tissue injury and detect foreign bodies
  • Chest radiograph for suspected Zone I injuries to detect hemopneumothorax, mediastinal air, or bleeding that extends into the upper mediastinum
Physical Exam
  • Signs and symptoms vary depending on the specific structures injured.
  • Vascular injury:
    • Active hemorrhage or hematoma
    • Tracheal deviation
    • Loss of normal anatomic landmarks
    • Pulse deficits in upper extremities
    • Thrills or bruits in neck
    • An intact pulse does not rule out a vascular injury.
  • Laryngotracheal injury:
    • Respiratory distress
    • Hoarseness, voice changes
    • Hemoptysis
    • Neck pain or tenderness
    • Crepitus/SC emphysema
  • Pharyngoesophageal injury:
    • Dysphagia
    • Odynophagia
    • Hematemesis
  • Neurologic injury:
    • Central or peripheral nervous system deficits
    • Horner's syndrome
Diagnostic Tests & Interpretation
Can be divided by best tests to detect damage to a particular system; however, since there is no consensus on the best diagnostic approach, all decisions should be made in cooperation with the trauma service.
  • Aerodigestive:
    • Multidetector helical CT with esophageal studies (contrast swallow with endoscopy)
  • Laryngotracheal injury:
    • Multidetector helical CT in stable patients
  • Vascular injuries:
    • Stable patients can undergo multidetector helical CT with angiography (MDCT-A). The sensitivity and specificity of this approaches traditional angiography, which was the former gold standard. However, MDCT-A is faster and more readily available (2)[B].
    • Color flow Doppler combined with frequent, repeated physical exam is a fast, noninvasive therapeutic modality; however, this does not fully evaluate injuries to Zone I or III, is operator-dependent, and can miss subtle findings.
  • Pharyngoesophageal injury:
    • Obvious clinical findings are frequently absent in esophageal injuries requiring surgical intervention.
    • Should always suspect esophageal injury in Zone I injuries.
    • MDCT is being used increasingly to evaluate esophageal injury.
    • The chest x-ray can demonstrate nonspecific findings, but does not rule out esophageal injury.
    • 100% sensitivity is reached only with the combination of esophagography and flexible endoscopy (3)[B].
Lab
  • Type and crossmatch
  • Baseline complete blood panel and chemistry panel
  • Coagulation studies
Differential Diagnosis
  • Vascular injury
  • Pharyngoesophageal injury
  • Laryngotracheal injury
  • Peripheral or central nervous system injury
  • Cervical spine injury
  • Associated head or thoracic trauma

P.405


Codes
ICD9
  • 874.00 Open wound of larynx with trachea, uncomplicated
  • 874.01 Open wound of larynx, uncomplicated
  • 874.02 Open wound of trachea, uncomplicated


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