Penetrating neck trauma

Ramsurya. A1, Angel Roselin S2

Emergency Medical Technician, Kauvery Hospital, Tirunelveli

Deputy Nursing superintendent, Kauvery Hospital, Tirunelveli

Introduction

Penetrating neck trauma is a very uncommon trauma with the high potential for significant morbidity & possible mortality if not treated immediately. Penetrating neck injury represents 5- 10% of all trauma cases. It is important for the physicians and the emergency nurses to identify the type of the injury and to manage the case crucially to improve the morbidity.

Background

Penetrating neck injury describes trauma to the neck that has breached the platysma muscle. The most common mechanism of injury worldwide is a stab wound from violent assault, followed by gunshot wound, self- harm, road traffic accidents, occupational injury and other velocity objects. The neck is a complex anatomical region containing important vascular, aero-digestive and neurological structures that are relatively unprotected.7 Vascular injury may include partial or complete occlusion (most common), dissection, pseudo-aneurysm, extravasation of blood or arteriovenous fistula formation. Arterial injury occurs in approximately 25% of penetrating neck injuries; carotid artery involvement is seen in approximately 80% and vertebral artery in 43%. Combined carotid and vertebral artery injury carry both major hemorrhagic and neurological concern. Aero-digestive injury occurs in 23–30% of patients with penetrating neck injuries and is associated with a high mortality rate.6 Pharyngo-esophageal injuries are less common than laryngo-tracheal injuries but both are associated with a mortality rate of approximately 20%. Neurological structures at risk of involvement include the spinal cord, cranial nerves VII–XII, the sympathetic chain, peripheral nerve roots and brachial plexus. Spinal cord injury occurs infrequently (less than 1%), particularly in low velocity injuries such as stab wounds.

The assessment and management of penetrating trauma to the neck has traditionally centered on the anatomical zone-based classification first described by Monson et al. in 1969 (Fig 1) More recently, the rigidity of this zone-based algorithm has been challenged, especially with regard to the mandatory exploration for zone II injuries. Routine neck exploration in hemo-dynamically stable patients leads to a high rate of nontherapeutic intervention, missed injuries, increased length of hospital stays and an increased rate of complications. Additionally, Low et al. demonstrated in 2014 a poor correlation between the location of the external wound and the injuries to internal structures.

These factors have brought into question the entire foundation of the traditional zonal approach. This review outlines a selective, non-zonal approach to penetrating neck injuries, where the entire neck is treated as a single entity.

Fig (1): Classification of anatomical zones of the neck (Monson 1969). Zone 1 extends from clavicles to cricoid, zone II from cricoid to angle of mandible, and zone III from angle of mandible to skull base

Initial Assessment & Stabilization

Patient with penetrating neck injuries can be transported immediately to the nearest trauma center.

Never remove the impaled object from the field.

Surgical consent is immediately required to determine the management of the case. Use of local anesthesia can be facilitated to better & accurate assessment. If the platysma is intact then, by definition, the wound is superficial. If the platysma is violated then it is a penetrating neck injury and the patient’s signs and symptoms govern how to proceed with management.4 Surgical consultation should be obtained in all penetrating neck injuries, particularly because the patient may initially appear stable but may decompensate rapidly. This is preferably achieved with an attending emergency otolaryngology team.

Cervical spine immobilization is not routinely recommended in penetrating neck injuries. The incidence of unstable cervical spine fractures in penetrating neck injuries is very low and cervical spine collars may obscure clinical signs and impair intubation.

The exceptions to this are if there is focal neurology or a high clinical suspicion for spinal injury in an unconscious or heavy intoxicated patient. Additionally, the incidence of cervical spine injury and cervical spinal cord injury has been demonstrated to be significantly different depending on the mechanism of injury. Penetrating neck injuries that result from high energy injuries, such as gun shots or blunt force as in motor vehicle accidents, are at higher risk of cervical spine injury and immobilization needs to be considered.

Airway Management

Immediate consideration should be given to the airway in a systematic approach and must address the following questions:

  • Does the patient require immediate airway protection?
  • What is the best approach and technique for airway protection?

This initially includes careful clinical examination for injury to the aero-digestive tract (oral, pharyngeal, laryngeal or tracheal) clinical signs of airway injury include hoarseness, stridor, dyspnea, subcutaneous emphysema (in the absence of pneumothorax), bubbling from the wound and large volume hemoptysis. The best method of achieving definite airway control in the setting of penetrating neck injury will vary according to the clinical circumstances, clinical skill and hospital resources.

It is imperative to be prepared for unexpected difficulty. Have available at least two suction devices, a range of different sized tracheal tubes, rescue airway devices and a surgical airway kit. Additionally, it is best to avoid airway techniques not performed with direct visualization, as blind placement of a tracheal tube into a lacerated tracheal segment can create a false lumen outside the trachea or convert a partial tracheal laceration into a complete transection.

When the airway is threatened but anatomic structures are preserved, we recommend rapid sequence intubation to secure the airway. Several studies at major trauma centers have found this to be a safe and effective approach to definite airway control. Bag and mask ventilation to preoxygenate in preparation for rapid sequence intubation or to reoxygenate following a failed attempt at intubation must be done with vigilance, as it may force air into injured tissue planes and distort airway anatomy or further disrupt surrounding soft tissue injury. If tracheal intubation is deemed necessary and the airway is predicted to be difficult because of distorted anatomy, we recommend fibreoptic intubation. Fibreoptic laryngoscopy and intubation allows the clinician to determine the integrity of the interior of the supraglottic and infraglottic airway while the patient maintains spontaneous respiration. This technique is limited by a patient’s level of cooperation and ability to tolerate the procedure.

Invasive airway management represents the standard approach when orotracheal intubation by any method is unsuccessful or contraindicated. Immediate indications for a surgical airway include massive upper airway distortion, massive midface trauma and inability to visualize the glottis because of heavy bleeding, oedema or anatomical disruption.

Cricothyotomy and tracheotomy are the two most commonly used procedures for severe neck trauma. We recommend cricothyrotomy as the first surgical airway of choice, as it is the most direct, simple and safe way of bypassing upper airway obstruction or injury. This may be difficult in the presence of distorted neck anatomy or if an anterior neck haematoma or laryngeal injury is suspected and carries potential risk to the vocal cords. Tracheotomy may be necessary in the event of skeletal collapse, significant structural airway disruption and breakdown and/or partial or complete transection of the larynx or trachea. The tracheotomy incision should be made as low in the neck as possible to avoid further injury to the laryngotracheal complex. The cervical incision should be made vertically, which allows for inferior extension if becomes necessary to achieve better anatomic exposur.Tracheotomy, even when performed by experienced hands, is the primary cause of long-term laryngotracheal complications and should therefore only be performed if indicated.

Surgery & conservative management

The decision to take a patient presenting with a penetrating neck injury immediately for surgical intervention is largely dependent on the physiological status and clinical findings on examination.12 If there is evidence of hemodynamic instability or what trauma centers refer to as ‘hard signs’ of injury to vital structures of the neck (Box 1), the patient should undergo operative exploration and bypass imaging.

The absence of hard signs does not exclude injury to underlying structures and the decision to take the patient to the operating theatre therefore depends on whether the physiological status of the patient is unstable

Surgical techniques for repairing injury to vital structures are discussed below.

‘Hard signs’ indicating immediate explorative surgery in penetrating neck injury.

  • Shock
  • Pulsatile bleeding or expanding hematoma
  • Audible bruit or palpable thrill
  • Airway compromise
  • Wound bubbling
  • Subcutaneous emphysema
  • Stridor
  • Hoarseness
  • Difficulty or pain when swallowing secretions
  • Neurological deficits

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