Zones of the neck
In the ED: Hemorrhage Control and Systematic Assessment
Severe active hemorrhage from a neck wound might require rapid hemostasis before further diagnostics or definitive surgical control can be planned. Even in the neck, direct compression is the initial maneuver and can control bleeding in many cases. For non-compressible hemorrhage in the neck or upper chest, balloon tamponade with a Foley catheter is an effective method to provide temporary hemostasis.
Procedure: Balloon Tamponade of Non-compressible Hemorrhage in Neck or Chest
Insert a large (16 or 18 Fr) Foley catheter carefully into the wound and inflate the balloon with a small amount of saline until bleeding stops.
If inflation alone does not stop the hemorrhage, the catheter might have to be pulled back slowly to achieve hemostasis (Fig. 1.3).
Clamp the catheter and secure it with suture or tape.
Once temporary hemostasis has been achieved, obtain imaging if needed or transport the patient to the OR.
Once the patient’s airway has been secured and initial injuries have been assessed, management proceeds based on the patient’s hemodynamic status and presence or absence of “hard signs” of vascular or aerodigestive injury. Any patient who is unstable (with neck trauma as likely cause) or has hard signs of vascular or aerodigestive injury should go directly to the OR. Patients with “soft signs” of injury might still require operative intervention but can usually undergo imaging workup first as long as they are not unstable or at risk for airway loss.
Pulsatile bleeding or expanding hematoma
Audible bruit or palpable thrill overlying the major vascular structures
Hemodynamic instability not explained by other injuries
Neurologic deficits not explained by other injuries
Air bubbling from the neck (Fig. 1.4)
Severe hematemesis or hemoptysis
Reported active bleeding or severe blood loss in the field
Hematoma without active expansion
Small amount of hematemesis or hemoptysis
In the ED: Imaging for Neck Trauma
Computed tomography angiography (CTA) of the neck has essentially replaced traditional angiography as initial imaging tool. A negative neck CTA rules out significant vascular injury with very high sensitivity and specificity . It is important to inject the IV contrast for the CTA on the contralateral side of the anticipated injury to adequately visualize the subclavian vessels without artifact from the contrast bolus. CTA of the neck might be limited if metallic shrapnel is present in the neck , and it is less sensitive for esophageal and tracheal injury. If there is concern for aerodigestive injuries (based on trajectory, clinical signs, and/or imaging findings; Fig. 1.5), a bronchoscopy and swallow study with water-soluble contrast should be performed to rule out tracheal and esophageal injury, respectively. Upper endoscopy in addition to a contrast study is the most sensitive way of ruling out digestive tract injury. If the neck CTA demonstrates isolated venous injury including the IJ, hemodynamically stable patients can still be successfully managed non-operatively .
In the OR: Preparation and Positioning
Vessel loops and vascular clamps, e.g., Bulldog clamps
Argyle shunts (Medline Inc.) of various sizes (8, 10, 12, and 14 Fr), or other shunt types depending on local availability
Arterial embolectomy catheters of various sizes, e.g., 3 and 5 Fr
Heparin flush (5000 units in a syringe with 100 ml of normal saline) for local, not systemic, administration
Thoracotomy and sternotomy set (at least sternal saw/Lebsche knife and Finochietto retractor)
The patient is positioned supine with both arms tucked to allow for good access to both sides of the neck. If the cervical spine has been cleared (generally, patients with penetrating neck trauma do not require c-spine immobilization), slight extension (shoulder roll) and contralateral rotation of the neck for unilateral injuries are helpful. Standard trauma prep, i.e., from head to bilateral knees, allows for access to the chest and lower extremities to harvest a venous conduit, if needed. For optimal exposure and to facilitate orientation, the mandible, angle of the mandible, and mastoid process should be visible. Ideally, to allow for optimal visibility of the entire face, use a transparent drape or forgo the top drape.
In the OR: Neck Exploration
The most versatile and commonly used incision for neck trauma follows the anterior aspect of the SCM. This incision can be extended (1) onto the chest if sternotomy is required; (2) across the neck to access trachea and esophagus from anterior; and (3) to the contralateral side of the neck if bilateral exposure is necessary (Fig. 1.6). For anterior injuries to the trachea and esophagus, a collar incision with the head in midline can be performed. This incision can also be extended to either side of the neck and onto the chest if needed (Fig. 1.7).