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Updated: Dec 17 2021

Neck Trauma

Images of neck trauma.jpg
  • Snapshot
    • A 27-year-old male is brought in to the ED after being found down in front of his apartment. The neighbors report that the patient was a stabbing victim, and a small knife was found on the left neck by EMS and left in place. En route, the patient’s blood pressure is 91/53 mmHg, pulse is 110/min, respirations are 21/min, and oxygen saturation is 95% on room air with GCS of 15. On exam, there is a small knife on the lateral left neck above the sternal notch with a large hematoma that feels pulsatile. There are decreased breath sounds on the left apical lung. There are also multiple stab wounds and lacerations on his back.
  • Introduction
    • Neck trauma can be described neck zones
      • zone I: base of neck (thoracic inlet to cricoid cartilage)
      • zone II: midportion of neck (cricoid to angle of mandible)
      • zone III: superior aspect of neck
    • Mechanism of injury can determine zones and layers of neck involved
  • Presentation
    • Airway injury
      • larynx
        • history: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma
        • triad: hoarseness, subcutaneous emphysema, palpable fracture crepitus
        • other symptoms: hemoptysis, dyspnea, dysphonia
      • trachea/bronchus
        • history: deceleration, penetration, increased intrathoracic pressure
        • symptoms: dyspnea, hemoptysis
        • exam: subcutaneous emphysema, Hamman's sign (crunching sound synchronized to heart beat)
    • Pharynx/esophageal injury
      • hematemesis, difficulty swallowing, saliva exiting out of the wound, pneumomediastinum
    • Vascular injury
      • most common injury with penetrating neck trauma
      • hematoma, absent carotid pulse, bruit, shock
    • Nerve injury
      • vagus, spinal accessory, hypoglossal, phrenic nerves are at risk
      • symptoms associated with the specific nerve damaged
  • Management
    • General approach
      • patient should be transported to a trauma center. Meanwhile, immobilize neck to prevent further injury
      • primary survey
        • if penetrating neck trauma present, do NOT:
          • clamp structures (high risk of nerve damage)
          • probe with finger
          • insert nasogastric tube (risk of perforation/bleeding)
          • remove weapon/impaled object in the ED
        • presence of hemodynamic instability or “hard signs” of tissue injury prompt surgical intervention
          • hard signs include
            • vascular injury
              • pulsatile bleeding, expanding hematoma, bruit, signs of cerebral ischemia, absent carotid pulse
            • aerodigestive injury
              • bubbling from the wound, hoarseness, stridor, subcutaneous emphysema, respiratory distress
      • secondary survey
        • imaging
          • CXR and CT scan
          • asymptomatic patients may have time for CT angiogram, esophagoscopy or bronchoscopy to fully characterize extent of injury and dictate further management
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