II. Definition

  1. Injury with penetration of the platysma muscle

III. Symptoms

  1. Dysphagia
  2. Hoarseness
  3. Bleeding from nose or mouth
  4. Neurologic deficit
  5. Hypotension

IV. Signs

  1. Subcutaneous Emphysema
  2. Stridor
  3. Respiratory distress
  4. Expanding hematoma
  5. Active bleeding from wound site
  6. Carotid Bruit
  7. Loss of pulse
  8. Neurologic deficit (presumed ischemia)

V. Exam: Wound Evaluation

  1. Clean blood from wound
  2. Determine if platysma was breached (if possible)
  3. Estimate wound depth and trajectory based on observation
    1. Avoid probing neck wounds to determine depth

VI. Exam: Localization of underlying injuries

  1. Determine depth of penetrating injury
    1. Injuries superficial to the platysma muscle may be repaired in normal fashion
    2. Injuries deep to the platysma muscle are high risk for serious injuries to underlying major structures
  2. Determine anterior triangle or posterior triangle injury
    1. Anterior triangle (Anterior to sternocleidomastoid)
      1. Most major structures (major vessels, trachea, esophagus)
    2. Posterior triangle (Posterior to sternocleidomastoid)
      1. Spinal Column (rare injury from Spinal Trauma)
    3. Images
      1. ErTraumaNeckAnterior.jpg
  3. Determine Zone of injury (Zone 1 inferiorly to Zone 3 superiorly)
    1. Precautions
      1. Injury zones play a reduced role in current day Penetrating Neck Trauma
        1. As of 2013, evaluation is exam-based with CT Angiography
        2. See evaluation protocol below
      2. Injury zones were originally developed to risk stratify patients based on ease of surgical exploration
        1. Zone 2 injuries are less difficult to explore than Zone 1 and 3
        2. Zone 2 Penetrating Trauma was typically explored in OR
          1. Resulting large number of unnecessary explorations
        3. Zone 1 and 3 Penetrating Trauma evaluation is more difficult
          1. Typically required complicated evaluation protocols including standard angiogram
    2. Zone 1 (sternal notch to cricoid ring/clavicle head)
      1. Lung apex (injury results in Pneumothorax, Hemothorax)
      2. Common Carotid Artery
      3. Subclavian artery
    3. Zone 2 (cricoid ring to angle of Mandible) - Highest risk region
      1. Internal Carotid Artery
      2. Internal Jugular Vein
      3. Sympathetic trunk (injury results in Hypotension)
      4. Recurrent laryngeal nerve (injury results in Hoarseness)
      5. Trachea
      6. Esophagus
    4. Zone 3 (angle of Mandible to skull base)
      1. Vertebral Artery
      2. External Carotid Artery
  4. Determine trajectory
    1. Penetrating injury toward vital structures (e.g. medial trajectory) or
    2. Penetrating injury away from vital structures (e.g. lateral trajectory)

VII. Evaluation

  1. Immediate surgery indications (hard signs of serious injury)
    1. Arterial injury
      1. Cerebral ischemia (e.g. new Hemiplegia suggesting carotid injury)
      2. Unstable patient with shock assumed secondary to neck Trauma
      3. Expanding or pulsatile hematoma
      4. Severe active bleeding (pulsatile bleeding, arterial bleeding)
      5. Refractory shock state
      6. Radial pulse diminished or absent on the side of injury
      7. Arterial Bruit or thrill
    2. Aerodigestive injury (less common)
      1. Airway obstruction
      2. Hemoptysis
      3. Hematemesis
      4. Wound with air bubbling through
  2. Intermediate cases (platysma penetration without hard signs)
    1. CT Angiography of Neck in most patients
      1. Test Sensitivity: 100%
      2. Test Specificity: 97.5%
      3. Osborn (2008) Trauma 64(6): 1466-71 [PubMed]
      4. Thoma (2008) 32(12): 2716-23 [PubMed]
      5. Vick (2008) Am Surg 74(11):1104-6 [PubMed]
      6. Inaba (2012) J Trauma Acute Care Surg 72(3): 576-83 [PubMed]
    2. Consult with Trauma surgery for local protocols
  3. CT Angiography of Neck based decision making
    1. Obvious CTA abnormalities requiring operative management
      1. Immediate surgery
    2. Intermediate CTA findings (possible aerodigestive injuries): Options for evaluation
      1. Bronchoscopy
      2. Laryngoscopy
      3. Upper endoscopy
      4. Barium Swallow
    3. No obvious CTA abnormalities to indicate immediate surgery
      1. Consult local Trauma surgery for recommendations
      2. Penetration trajectory toward vital structures
        1. Admit for observation
      3. Penetration trajectory away from vital structures
        1. Observe for 6-12 hours
        2. May discharge if stable following observation

VIII. Management

  1. Cervical Spine Immobilization indications
    1. Neurologic deficit
    2. Altered Level of Consciousness
  2. Bleeding control
    1. Apply pressure
    2. Do not clamp due to significant risk of collateral damage
  3. Venous access
    1. Obtain on opposite side of injury
  4. Advanced Airway management (intubation, Cricothyrotomy)
    1. See Advanced Airway for general indications
    2. Absolute indications for Advanced Airway
      1. Decreased mental status
      2. Expanding hematoma
      3. Tracheolaryngeal injury (Tracheal Tear, Laryngeal Fracture)
      4. Hypoxia
      5. Hypoventilation
    3. Additional indications to consider for Advanced Airway
      1. Interhospital transfer
      2. Risk of progressive airway compromise
        1. Early Advanced Airway placement is preferred if risk of progression
    4. Technique
      1. Rapid Sequence Intubation
      2. Video Laryngoscopy or Fiberoptic intubation over bronchoscope if available
      3. Consider double set-up for immediate Cricothyrotomy as a backup plan
      4. Avoid blind techniques (risk of exacerbating airway injury)
        1. Avoid Extraglottic Devices (e.g. LMA, Combitube)
        2. Avoid Nasotracheal Intubation

IX. References

  1. Inaba and Spangler in Herbert (2016) EM:Rap 16(11): 5
  2. (2008) ATLS Manual, American College of Surgeons
  3. Birnbaumer in Majoewsky (2012) EM:Rap 12(10): 9-11
  4. Inaba and Herbert in Majoewsky (2013) EM:Rap 13(3): 7

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Ontology: Penetrating wound of neck (C1997695)

Concepts Injury or Poisoning (T037)
SnomedCT 428152007
English Penetrating wound of neck, Penetrating wound of neck (disorder)
Spanish herida penetrante de cuello (trastorno), herida penetrante de cuello