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Neck Lacerations and Penetrating Injuries

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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


Treatment
  • Airway management:
    • Although penetrating neck trauma often does not involve the cervical spine, the cervical spine should be evaluated and cleared appropriately. Airway management should be done with the patient in cervical spine precautions until cleared.
    • Patients who are comatose or in respiratory distress require immediate intubation.
    • Stable patients without evidence of respiratory distress may be aggressively managed with prophylactic intubation or closely observed with airway equipment at the bedside.
    • Bag-valve-mask can force air through fascial planes and should be done carefully.
    • Orotracheal intubation with rapid sequence induction is the method of choice for securing the airway.
    • Nasotracheal intubation is contraindicated with apnea, severe facial injury, or airway distortion because of the risk of puncturing an expanding hematoma.
    • Fiber-optic intubation is contraindicated with active bleeding that may obscure the scope.
    • Percutaneous transtracheal ventilation may be useful when oral or nasotracheal intubation fails and should be used only as a temporizing measure until a more secure airway is obtained. Care should be taken to ensure proper placement:
      • Leaves the airway unprotected and is contraindicated in cases of upper airway obstruction, as it may cause barotrauma
    • If the trachea is exposed due to a complete or partial transection, the caudal end should be directly intubated.
    • In all patients in whom intubation is attempted, there should be a surgical airway kit at the bedside. The physician must be prepared for a cricothyroidotomy or tracheostomy, as these are required in cases of severe facial injury, laryngotracheal injury, and uncontrolled upper airway hemorrhage.
  • Breathing:
    • Zone I injury can cause pneumothorax or subclavian vein injury and hemothorax, requiring needle decompression and tube thoracostomy.
  • Circulation:
    • 2 large-bore IVs should be placed contralateral to the side of the injury to avoid ipsilateral venous injury.
    • External hemorrhage should be controlled with direct pressure. Blind clamping of vessels is contraindicated due to the risk of further neurovascular injury.
    • If bleeding cannot be controlled, a Foley catheter can be inserted and inflated with saline to help tamponade the bleeding.
    • Patients with uncontrolled bleeding or hemodynamic instability must go directly to the operating room.
Pre-Hospital
  • Impaled objects should not be removed.
  • Gently suction to clear the airway of blood, secretions, or vomitus.
  • Lateral decubitus or prone positioning may be required to prevent aspiration.
  • The airway must be vigilantly monitored, as edema or expanding hematoma can progress to airway compromise.
  • Early oral intubation is indicated for clinical signs of respiratory distress, such as stridor, air hunger, or labored breathing, or if an expanding neck hematoma is present.
ED Treatment
  • Alert and seemingly stable patients are known to rapidly decompensate; therefore, an airway setup should be at the bedside.
  • Nasogastric tube should not be placed due to risk of rupturing a pharyngeal hematoma.
  • Prophylactic antibiotics are recommended (cefoxitin, clindamycin, penicillin G plus metronidazole).
  • Surgical consult for all wounds that penetrate the platysma muscle
  • There is controversy regarding mandatory vs selective surgical exploration in stable patients, especially in those with Zone II injuries:
    • Mandatory approach:
      • Surgical exploration is indicated in all cases of penetrating neck trauma because significant injury may not manifest outward signs or symptoms.
    • Selective approach:
      • Supported by the research
      • Surgical exploration for specific indications, including expanding or pulsatile hematoma, active bleeding, absence of peripheral pulses, hemoptysis, Horner's syndrome, bruit, SC emphysema, respiratory distress, or air bubbling through a wound
  • Tetanus prophylaxis
  • Traumatic arrest in patients with penetrating neck injury is an indication for the emergency department thoracotomy.
Medication
  • Cefoxitin: Adult: 2 g IV q8h; peds: 80–160 mg/kg/day IM/IV div q6h or
  • Clindamycin: Adult: 600–900 mg IV q8h; peds: 25–40 mg/kg/day IV div q6–8h or
  • Penicillin G: Adult: 24 million IU/day div q4–6h; peds: 150,000–250,000 IU/kg/day div q4–6h plus
  • Metronidazole: Adult: 1 g load, then 500 mg IV q6h; peds: 30 mg/kg/day IV div q12h
Additional Treatment
General Measures
Esophageal and venous injuries are subtle and often missed.
In-Patient Considerations
Admission Criteria
  • All patients with penetrating neck trauma should be admitted and observed for at least 24 hr.
  • Observation must take place in a facility capable of providing definitive surgical care.
  • Patients with possible airway or vascular injury must be admitted to the intensive care unit.
Discharge Criteria
Asymptomatic patients who have negative studies may be discharged after at least 24 hr of observation.
References
1. Kendall JL, Anglin D, Demetriades D. Penetrating neck trauma. Emerg Med Clin North Am. 1998;16:85–105.
2. Biffl WL, Moore EE, Rehse DH, et al. Selective management of penetrating neck trauma based on cervical level of injury. Am J Surg. 1997;174:678–682.
3. Arantes V, Campolina C, Valerio SH, et al. Flexible esophagoscopy as a diagnostic tool for traumatic esophageal injuries. J Trauma. 2009;66:1677–1682.
Additional Reading
Inaba K, Munera F, McKenney M, et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma. 2006;61:144–149.
Thal ER, Meyer DM. Penetrating neck trauma. Curr Probl Surg. 1992;29:1–56.
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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