Penetrating neck trauma
RED FLAGS
Neck trauma with noisy breathing or laryngeal voice change: hoarse, croaky or no voice
Expanding swellings in the neck that could be indicative of haematoma
Neck wound with profuse active bleeding, massive subcutaneous surgical emphysema, air bubbling from the wound or frank haemoptysis
Neck wound in a patient with cardiorespiratory instability
WHY IS THIS IMPORTANT?
There is a potential for high mortality (c. 5%) and morbidity in patients with penetrating neck injuries (PNI).
This reference page is written with significant PNI (eg high-risk mechanism of injury and breach of platysma) in mind.
WHO TO ADMIT
Consider admission of all patients with significant PNI. Where the mechanism and evidence of injury suggest a non-significant wound such as a superficial, low velocity injury, consider lavage and closure after discussion with a senior colleague.
WHEN TO INVOLVE THE ENT REGISTRAR
Immediately - any PNI with red flags or an unstable patient.
Soon - any PNI where both mechanism (history) and evidence (examination) suggest a significant or deep injury.
ASSESSMENT, RECOGNITION & INITIAL MANAGEMENT
History
Take a focused history (AMPLE and mechanism of injury); you may have to rely on collateral history from bystanders/paramedics.
If appropriate, take a more detailed head and neck history, concentrating on symptoms such as odynophagia, otalgia and voice change.
Primary survey
Assess and resuscitate the patient according to relevant trauma life support guidelines. A trauma team or equivalent should be in attendance.
The airway should be managed along with control of the cervical spine, if appropriate (eg high velocity mechanism; patient with low GCS or focal neurology)
The multidisciplinary team should consider rapid sequence intubation or front of neck access
Active bleeding: place firm direct pressure over the bleeding site.
Do not compromise the airway.
Do not use too many layers of swabs or dressings as this will obscure the wound and/or airway and any pressure applied will become diffuse and ineffective.
Consider the use of adjuncts: Foley catheter inserted into the wound for tamponade; haemostatic granule dressings such as Celox or QuickClot.
Bubbling or sucking neck wounds: place occlusive dressing with diffuse pressure; place head down on left side if necessary.
Other initial management steps:
Keep the patient nil by mouth (NBM).
Apply humidified oxygen or frequent saline nebulisers to support the airway.
Perform flexible nasendoscopy to assess the airway and for signs of trauma such a blood, clots and mucosal disruption
Start antibiotics where there is a grossly contaminated wound or significant risk of visceral injury
Re-assess the patient at frequent intervals.
Secondary survey
Assess the neck wound when indicated by trauma life support protocol: wear appropriate protective equipment.
Inspect and examine the neck closely and note any findings such as surgical emphysema or size and site of any wound(s).
Assess the risk that removing adherent dressings, weapons or foreign bodies will cause significant bleeding: prepare for the worst.
In an unstable patient or where there has been a history of heavy bleeding, consider imaging first; in these cases, it is prudent to remove dressings etc. in the operating theatre in a relatively more controlled fashion.
Consider cross-sectional imaging for the neck, taking into account the likelihood of vascular injury and working with other teams to determine whether other injuries outside the head and neck also require imaging. For neck injuries specifically:
Catheter angiography is considered the gold-standard for vascular imaging, but most units will only have access to urgent CT scanning.
Contrast-enhanced CT angiography is very helpful in this situation and provides valuable information on the presence and extent of vascular injuries, haematomas, pneumothorax and frank disruptive/displaced injuries to the aerodigestive tract. It cannot rule out more subtle injuries which may still be life-threatening for the patient: consider rigid endoscopy or a water-soluble contrast swallow.
Classification
PNIs can be initially classified as high-velocity (eg firearm projectiles) or low-velocity injuries (eg stab injury). Describe them according to anatomical zone (see bottom of page for references):
Zone 1: Clavicles to level of cricoid cartilage
Generally, the contents (subclavian artery and vein, apex of lung, brachial plexus, oesophagus, trachea etc.) are less frequently injured but injuries in this area carry the highest rate of mortality
Zone 2: Level of cricoid cartilage to angle of mandible
This area is generally the most-injured. Beware of trauma to the larrynx, pharynx, carotid and vertebral arteries, jugular veins and cranial nerves X, XI and XII.
Zone 3: Angle of mandible to skull base
Injuries are rarer in this zone. Contents include the great vessels (as above), the pharynx, spinal cord and cranial nerves XI and XII.
The presence red flags in an unstable patient indicates immediate surgical exploration with parallel resuscitation. Conversely, asymptomatic patients with negative physical examinations and investigations may be managed conservatively. Management decisions are typically a multidisciplinary affair with input from senior clinicians.
FURTHER MANAGEMENT
Manage the patient in light of the results of initial investigations. Wounds that turn out to be smaller and superficial than initially thought can be washed and closed in the emergency department.
More significant or deep wounds should be dealt with in the operating theatre for exploration including rigid endoscopy, washout, repair, drains and closure depending on the site and type of injury.
Many patients with a significant PNI should be observed for a period of time before discharge. Consider:
Limited antibiotic prescription as guided by a local microbiologist
Anti-reflux medication
Interval flexible nasendoscopy
Voice rest
Speech and language therapist assessment and treatment
Interval water-soluble contrast fluoroscopic swallow
See Airway trauma for more information.
References
Tisherman et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008.
Page last reviewed: 12 October 2022