Penetrating Neck Trauma Algorithm

Presentation of Patient Stab wound at the right side of the neck at the level of the cricoid Airway is patent No blood in the oral cavity Crepitation in the neck Continuous bleeding from the stab wound site Symmetrical chest expansion; equal breath sounds Abdomen soft, non‐tender BP = 90/60 PR = 100/min RR = 25/min

Initial Care: Approach to the Unstable Patient Airway Early orotracheal intubation Cricothyroidectomy as last resort Oxygenation * If spontaneous ventilation appears adequate close observation and pulse oximetry * Inadequate spontaneous respiration (hematoma, obstruction, swelling) - emergency intubation

Initial Care: Approach to the Unstable Patient Breathing Ensure no concomitant injury or pneumothorax Circulation Stop external bleeding (finger) IV access & judicious fluid resuscitation Disability Check neurology (GCS and lateralizing signs) Exposure Check for other wounds

Initial Care: Approach to the Unstable Patient Adequate peripheral intravenous catheter lines of 16 gauge or larger Blood for crossmatching and routine evaluation Fluid resuscitation After initial resuscitation – complete physical examination to detect associated injuries and better define extent of neck trauma

Penetrating Neck Trauma Algorithm

Rules on Exploration All symptomatic patients are explored Work-up is irrelevant in the presence of clinical signs of injury *Zone I injuries liberally explored difficult vascular control disastrous consequences with delay

Signs of Significant Injury in Penetrating Neck Trauma VASCULAR INJURY Shock Active bleeding Large/expanding hematoma Pulse deficit

Clinical Indications for Neck Exploration Vascular -shock (BP 90/60 PR 100/min RR25/min -active bleeding -large or expanding hematoma -pulse deficit Airway -dyspnea – talks in phrases -stridor -hoarseness -dysphonia or voice change -subcutaneous emphysema – crepitation in neck Digestive tract -hemoptysis -dysphagia/odynophagia -hematemesis -subcutaneous emphysema Neurologic -Focal or lateralized neurologic deficit Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air occurs when gas or air is present in the subcutaneous layer of the skin Subcutaneous crepitus (or surgical emphysema) is a crackling sound resulting from subcutaneous emphysema, or air trapped in the subcutaneous tissues. Subcutaneous emphysema can result from puncture of parts of the respiratory or gastrointestinal systems. Particularly in the chest and neck, air may become trapped as a result of penetrating trauma (e.g., gunshot wounds or stab wounds) or blunt trauma. Infection (e.g., gas gangrene) can cause gas to be trapped in the subcutaneous tissues. Subcutaneous emphysema can be caused by medical procedures and medical conditions that cause the pressure in the alveoli of the lung to be higher than that in the tissues outside of them.[3] Its most common causes are pneumothorax and an improperly functioning chest tube. Chest tubes have a tendency to form clot in them or become occluded with fibrinous material. In the setting of an air leak, when chest tube occlusion or clogging, occurs, sub cutaneous emphysema will occur. It can also occur spontaneously due to rupture of the alveoli, with dramatic signs.[4]

Surgical Neck Exploration Neck exploration should be performed in the operating room under general endotracheal anesthesia Hemodynamically stable patient with a patent airway – intubation can be deferred until laryngoscopy and bronchoscopy have been performed Nasogastric tube is passed to ensure an empty stomach Chest auscultation

Neck Exploration Incisions

Management of Specific Injuries Blood vessels – most commonly injured Hemostasis should be maintained by direct pressure or digital occlusion until proximal and distal control of vessel is achieved Choice of graft material should be based on size Polytetrafluorethylene is commonly used