1. Penetrating Neck Trauma Algorithm

2. 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

3. 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

4. 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

5. 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

6. Penetrating Neck Trauma Algorithm

7. 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

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

9. 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]

10. 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

11. Neck Exploration Incisions

12. 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