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The Pre-brief
I know what zone the neck injury is in…now what?
As a recap: Trauma to the neck is bad. There are 3 zones (see previous neck trauma post). In fact, the zones don’t really matter. What matters is how your patient is doing.
Stable penetrating trauma?
- You don’t know the trajectory of penetrating trauma, so it is always best to assume and evaluate for all possible injuries.
- Know what anatomical structures can be affected.
- Sclafani et al. found that physical examination for neck trauma has a sensitivity of 61% and specificity of 80%.1 Which means you should consider imaging even in a stable patient.
- Lack of obvious platysma violation should not deter a complete evaluation.
Unstable penetrating trauma?
While all roads lead to the operating room, there are a few steps to get through first.
You don’t want your patient to continue to bleed in front of you.
- Take a deep breath, then make sure the patient can too; if not, intubate (either person)
- Take down the dressing and put a gloved finger over the bleed or an entire palm if necessary
- You can insert a foley catheter and inflate the balloon to tamponade bleeding (this works for cardiac puncture trauma as well)2
– DO NOT PROBE wounds with active bleeding as this can dislodge a clot (for that matter, you should not probe any of these wounds if your surgical colleague is not next to you) - If there is respiratory distress, stridor, hemoptysis, or air bubbling from the neck wound assume there is an airway injury and consider early intubation.
– Intubate with first pass success in mind. You can give RSI meds the way you normally would, but awake intubation might be more beneficial if the situation allows.
– Use a smaller ET tube if tracheal injury is suspected. - Consider careful* cricothyrotomy if the airway is obscured by copious blood
– The anatomy may be distorted
– Cricothyrotomy is relatively contraindicated if an anterior neck hematoma exists or a laryngeal injury is suspected but may be the only viable option in some patients - Consider chest tube placement for pneumothorax for lower neck wounds with decreased breath sounds or lack of pleural movement on bedside EFAST or worsening subcutaneous air.
Once A and C are controlled, remember that there is a whole patient to assess. Start your trauma survey from the top to make sure you don’t miss any injuries.
The Debrief
- With penetrating neck trauma, determine in what zone your patient is injured
- Then determine if your patient is stable or unstable
- Take control of the airway if needed
- Determine what kind of imaging is needed based on the location of the injury and which structures could potentially be damaged
References
- Sclafani SJ, Cavaliere G, Atweh N, et al. The role of angiography in penetrating neck trauma. J Trauma. 1991;31:557-562. PMID: 2020041.
- Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. World J Surg. 2006 Jul;30(7):1265-8. doi: 10.1007/s00268-005-0538-3. PMID: 16830215.
- Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35:221. PMID: 10692187.
- Kendall JL, Anglin D, Demetriades D: Penetrating neck trauma. Emerg Med Clin North Am 1998; 16(1): 85-105. PMID: 9496316.
- Tisherman, Samuel A. MD; Bokhari, Faran MD; Collier, Bryan DO; Cumming, John MD; Ebert, James MD; Holevar, Michele MD; Kurek, Stanley DO; Leon, Stuart MD; Rhee, Peter MD Clinical Practice Guideline: Penetrating Zone II Neck Trauma, The Journal of Trauma: Injury, Infection, and Critical Care: May 2008 – Volume 64 – Issue 5 – p 1392-1405 doi: 10.1097/TA.0b013e3181692116. PMID: 18469667.
