Neck Trauma

Question 1

Principles of penetrating neck trauma:

Answer 1

1- Zones I, II, III

2- PLATYSMA breach differentiates superficial/ benign, from deep/ concerning.
–> never probe through platysma

3- Hard vs soft signs

Question 2

Injury to which structure is most commonly missed (a cause of delayed death)?

Answer 2

Oesophagus

Question 3

Zones of the neck and their contents:

Answer 3

Zone I
Clavicles –> cricoid
- Subclavian a.v.
- Common carotid a.
- Int. and ext. jugular v.
- Brachial plexus
- Cord
- Trachea
- Oesophagus
- Thyroid
- Lung apex
- Thoracic duct

Zone II
Cricoid –> jaw angle
- *Int. and ext. carotid a.
- Vertebral a.
- Int. and ext. jugular v.
- Recurrent laryngeal n.
- Vagus n.
- Cord
- Larynx
- Oesophagus

Zone III
Jaw angle –> BOS
- Salivary glands
- Parotid gland
- Cranial nerves IX - XII

Question 4

Which zone is most commonly injured?

Answer 4

Zone II

Question 5

HARD signs in neck trauma:

Answer 5

90% rate major injury

Expanding haematoma
Bruit/thrill
Severe, active bleeding
Airway obstruction
Bubbling wound
Cerebral ischaemia (global)
Reduced radial pulses
Shock (unresponsive to fluids)

……go to OT!!

Question 6

SOFT signs in neck trauma:

Answer 6

Haematememis/ hamoptysis
Non-expanding haematoma
Oropharyngeal blood
Dyspnoea, dysphonia, dysphagia
Subcut or mediastinal gas
Air leak on chest drain
Focal neurological deficit

Question 7

GENERAL APPROACH to neck trauma:

Answer 7

Trauma call
ENT

Remove collar if able
–> Exposure for assess/ treat

Trendelenberg +/- (air embolism)

Control Airway
- Prep for front-of-neck
- Consider early intubation
- Try and use awake technique (or, ketamine)
- Avoid bagging (emphysema)

Control haemorrhage
- Direct pressure
- Foley

Assess:
- Zone involved
- ?through platysma
–> Do not probe beyond it.
- Hard and soft signs

Disposition
- Hard signs –> OT.
- Soft signs –> 3-zone CT angio
- Admit ALL with platysma breach
- Always think about oesophageal injury –> Low threshold gastrograffin

Question 8

List 5 options for securing airway in traumatised neck:

Answer 8

Ideally, don’t want patient to stop breathing!
–> May obstruct
–> Bagging can cause emphysema

Awake techniques are best!

1- RSI with direct laryngoscopy
2- Awake direct laryngoscopy with topicalisation
3- Awake fibreoptic
4- Awake tracheostomy
5- Awake cricothyroidotomy
6- Inhalational induction
7- Intubate through open tracheal injury

*Alternative to awake is Ketamine
**Be sure to sedate once tube is in.

Question 9

Injuries in the near-hanged patient:

Answer 9

In “judicial” hanging, death is from cord transection

In other hanging, death is primarily from vascular obstruction (not airway)

_______

• Cervical injury
  (requires judicial hanging):
  –> Hangman # (bilateral pedicles C2, anterolisthesis, cord transection)
  –> Cord injury
  –.> Neurogenic shock
• Trauma to:
  –> Larynx
  –> Vascular (dissection, thrombus)
  –> Oesophagus
• Strangulation:
  –> Conjunctival haemorrhage
  –> Petechiae
  –> Plethora
  –> An/hypoxic brain jury
• Delayed:
  –> Negative-pressure APO
  –> Neurogenic APO