INTRODUCTION

Penetrating neck injuries (PNIs) are notoriously difficult to evaluate and manage because of the complex anatomy and the dense concentration of numerous vital structures in a small anatomic area. The clinical evaluation can be challenging, and significant injuries may easily be missed. The radiologic evaluation of these injuries has undergone major changes since the early 2000s and shifted from invasive diagnostic procedures to noninvasive methods. The selection of the most appropriate investigation remains a controversial issue. The surgical exposure of some neck structures such as the distal carotid artery, the subclavian vessels, and the vertebral artery can challenge the surgical skills of even the most experienced trauma or vascular surgeons and require excellent knowledge of the local anatomy. The advancement of interventional radiology has revolutionized many aspects of the management of some complex vascular injuries that are difficult to manage operatively.

EPIDEMIOLOGY

Firearms are responsible for about 43%, stab wounds for about 40%, shotguns for about 4%, and other weapons for about 12% of all PNIs in urban trauma centers in the United States.¹ Gunshot wounds (GSWs) are significantly more likely to be associated with large neck hematomas, hypotension on admission, and vascular or aerodigestive injuries than are knife wounds.^1,2 Overall, about 35% of all GSWs and 20% of stab wounds to the neck are associated with significant injuries to vital structures, but only 16.5% of GSWs and 10.1% of stab wounds require a therapeutic operation. Transcervical GSWs are associated with significant injuries to vital structures in 73% of victims, although only 21% require a therapeutic operation.³

Shotgun injuries account for about 4% of civilian PNIs, often cause injuries to multiple structures, and pose major evaluation and management problems. Overall, the most commonly injured structures in the neck are the vessels, followed by the spinal cord, the aerodigestive tracts, and nerves.¹ The incidence of injury to the various neck structures according to mechanism of injury is shown in Table 79-1.

Table 79-1 Incidence and Type of Injuries according to Mechanism of Injury (N = 223 Patients)¹

ANATOMY

In penetrating trauma, the neck is divided into three anatomic zones for evaluation and therapeutic strategy purposes (Fig. 79-1): Zone I comprises the area between the clavicle and the cricoid cartilage. This zone includes the innominate vessels, the origin of the common carotid artery, the subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the esophagus, the apex of the lung, and the thoracic duct. The surgical exposure of the vascular structures in Zone I is difficult because of the presence of the clavicle. Zone II comprises the area between the cricoid cartilage and the angle of the mandible and contains the carotid and vertebral arteries, the internal jugular vein, the trachea, and the esophagus. This zone is more accessible to clinical examination and surgical exploration than the other zones. Zone III extends between the angle of the mandible and the base of the skull and includes the distal carotid and vertebral arteries and the pharynx. Zone III is not amenable to easy physical examination or surgical exploration.

Figure 79-1 Surgical zones of the neck: zone I is between the clavicle and the cricoid; zone II is between the cricoid and the angle of the mandible; and zone III is between the angle of the mandible and the base of the skull.

MANAGEMENT

The initial evaluation and management should follow the Advanced Trauma Life Support (ATLS) protocols. During the primary survey, the following life-threatening conditions from the neck should be identified and treated as soon as possible:

During the secondary survey the following neck injuries should be identified:

The more common pitfalls initially encountered when dealing with patients with PNI follow.

Failure to Secure the Airway

• Consequence

The presence of a large hematoma (Fig. 79-2) or edema or laryngotracheal trauma makes the endotracheal intubation difficult and dangerous, even in an ideal environment. Inability to secure the airway in such a patient can lead to severe respiratory distress and, ultimately, cardiac arrest.

Grade 4/5 complication

Figure 79-2 Patient with a large hematoma in zone I of the neck, secondary to subclavian artery injury.

• Repair

Cricothyroidotomy in the emergency room may be necessary in about 6% of all PNIs⁴ or about 12% of laryngotracheal injuries.⁵ In the presence of large midline hematomas, the procedure is difficult and may be associated with severe bleeding.

On rare occasions with visible large laryngotracheal wounds, the endotracheal tube can be inserted under direct view into the distal transected segment through the neck wound. The distal larynx or trachea should be grasped and secured with a tissue forceps before insertion of the tube in order to avoid complete transection or retraction into the mediastinum.

• Prevention

Early recognition of the need for surgical airway is key. Air bubbling through a neck wound is pathognomonic of laryngotracheal injury. Firm manual compression over the wound reduces the air leak and usually improves oxygenation. Emergency room endotracheal intubation should be considered only in patients who fail to improve after firm occlusion of the wound with the air leak. Orotracheal intubation in the emergency room should be performed by the most experienced physician present, with a surgeon ready to perform a surgical airway.

Active Hemorrhage

More than 20% of patients who sustain a PNI have evidence of vascular injury (see Table 79-1). Patients may present with a moderate to large hematoma or active bleeding, either externally or into the thoracic cavity.

• Consequence

Major active bleeding, externally or into the thoracic cavity, is potentially life threatening and needs to be addressed immediately after the airway has been secured. In addition, venous injuries may lead to air embolism. Without prompt attention, patients will suffer cardiovascular collapse.

Grade 3/4 complication

• Repair

On arrival at the hospital, patients with active bleeding should be placed in the Trendelenberg position to reduce the risk of air embolism in cases with venous injuries. In cases of suspected subclavian venous injuries, the intravenous line should be inserted in the opposite arm in order to avoid extravasation of infused fluids or medications from a proximal venous injury. External bleeding can successfully be controlled by direct pressure in most cases. However, bleeding from the vessels behind the clavicle or near the base of the skull or the vertebral artery is often difficult to control by external pressure. In these cases, digital compression with a gloved index finger through the wound should be attempted. For these situations, we have successfully used balloon tamponade.^6–8 The technique involves insertion of a Foley catheter into the wound and advancement as far as it can go. The balloon is then inflated with water until the bleeding stops or moderate resistance is felt. If the bleeding continues after this maneuver, the balloon is deflated and the catheter is slightly withdrawn and reinflated. Significant bleeding through the catheter is suggestive of bleeding distal to the balloon and repositioning should be attempted. In periclavicular injuries, the bleeding may occur in both the intrathoracic cavity and externally. In these cases, a Foley catheter is advanced into the chest cavity through the neck wound, the balloon is then inflated, and the catheter is pulled back until some resistance is felt. In this position, the balloon compresses the bleeding vessels against the first rib or the clavicle (Fig. 79-3). The traction is maintained by application of a Kelly forceps on the catheter, just above the skin. If external bleeding continues, a second Foley is inserted and inflated in the wound tract.⁷ Blind clamping of suspected bleeding should be avoided because it is rarely effective and the risk of further vascular or nerve damage is very high.

Figure 79-3 Balloon tamponade for bleeding control from the subclavian vessels. It can also be used for bleeding control from other zones in the neck.

Many patients with major injuries to the neck vessels reach the hospital in cardiac arrest or imminent cardiac arrest. These patients may benefit from a resuscitative thoracotomy. Bleeding from the left subclavian vessels can be controlled with a vascular clamp applied under direct view through the thoracotomy. Besides the usual resuscitation measures, the right ventricle should be aspirated for air embolism. In our experience, survival after resuscitative thoracotomy for PNI is very poor.⁹

• Prevention

The sequelae of hemorrhage can be minimized only by digital pressure and early recognition.

Diagnostic Work-up Impaired by a Cervical Collar

Cervical spine protection by means of a neck collar remains a common practice during the prehospital transportation of patients with PNIs. The value of this practice is questionable and may be harmful in some patients.

• Consequence

Spinal immobilization may complicate the evaluation and diagnostic work-up, and most importantly; the application of a cervical collar in the presence of a large or expanding hematoma may cause respiratory obstruction (see Fig. 79-2).

Grade 1/2 complication

• Repair

Removal of the collar.

• Prevention

Cervical spine protection has absolutely no role in patients with stab wounds to the neck. Its value in cases with GSWs is limited. It is rare that low-velocity GSWs result in spinal instability. In a series of 1300 patients with GSWs of the spine, Meyer and coworkers¹⁰ found no unstable fractures. However, it has been reported and it is also our experience, that in rare occasions, a low-velocity GSW can cause unstable spinal fractures without cord injury.¹¹ In high-velocity wounds, massive destruction of the bone and ligament structures of the cervical spine may cause instability. However, these injuries are always associated with irreversible cord destruction, making spinal immobilization of limited practical value. It is recommended that in knife injuries, no cervical collar is applied. In GSWs, a collar may be applied, always monitoring for expanding hematoma or respiratory distress. In these cases, the collar should be loosened to relieve the airway obstruction.

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