Happy EMS week! First, we would like to thank you for everything you do. You are available for your community in its most desperate times. What society expects from you—and what you expect from yourselves—is clinical excellence and compassionate care. Despite long hours and stressful situations, you provide just this, 24/7/365. Lately, your service has been at even more considerable risk to your own physical and mental wellbeing. But it’s not new for prehospital clinicians to be underpaid, understaffed, and underappreciated.
This EMS week, our first at EMS Cast, we’d like to move beyond statements of gratitude and ask you how we can serve you best. What would you like to learn from us? What would you like us to learn from you? We remember some of the frustrations of being paramedics, and we’d love to hear—from those of you still out in the field—what those of us in the hospital can do to make your incredibly difficult jobs even a little easier. Thank you.
Please contact us hereor comment below with podcast requests, comments, or questions.
Podcast: Matt Mendes MD NR–P, Ross Orpet MD NR–P, Maria Moreira MD FACEP
Show Notes: Tyler Prince M4 NR–P
Ep. 3 Penetrating Neck Wounds
Penetrating neck wounds have the potential to injure many key structures. We discussed these injuries with all-around EM expert Maria “The Hammer” Moreira, MD. This episode is rife with pearls and deserves a thorough listen.
Anatomy
Portions of many body systems pass through the neck
Neurologic: spinal cord
Respiratory: trachea, apices of lungs
Cardiovascular: carotid arteries, jugular veins, vertebral and subclavian vessels
Gastrointestinal: esophagus
Structures not in the neck can be involved depending on trajectory of wound
Zone 1 wounds are most likely to involve thoracic structures
Consider tension pneumothorax and cardiac tamponade; correct prior to intubation if possible
Be ready to do a cric! Can’t intubate, can’t oxygenate = CRIC
Circulation
Do not explore/probe neck wounds!
Provide direct pressure to open wounds throughout the entire call—may have fire or other first responder ride in and assume this role
Hemorrhagic shock: bilateral large bore IVs, blood products vs crystalloids
If tension pneumothorax is suspected, perform needle decompression prior to intubation
Disability
C-collars should be used only if a neuro deficit is present
Chance of C-spine injury in penetrating neck trauma is low
1.35% c-spine injury in GSWs to neck
0.12% c-spine injury in stabbings to neck
Actual spinal cord injury rates are even lower
Open collars and visualize the neck!
Definitive management throughout history
Defunct methods
Expectant management: 35% mortality
By zone:
Zone 1 = imaging
Zone 2 = surgical exploration
Zone 3 = imaging
Modern approach: “no zone”
“Hard signs” = OR emergently for surgical exploration
Hemodynamically unstable
Expanding hematoma or severe hemorrhage
Neuro deficits
Thrills or bruits
Absent radial pulse
Air bubbling from wound
Massive hemoptysis or respiratory distress
Soft signs = Imaging (CT angiography) to guide management
Mild hypotension
Minor hemoptysis
Subcutaneous air
Non-expanding hematoma
Dysphonia or dysphagia
If asymptomatic with platysma violation = observation 24 hours in order to monitor for the development of hard or soft signs.
If the platysma is intact, chance of damage to key structures is extremely low.
Takeaways
The neck contains key structures including the trachea, major vasculature, spinal cord, esophagus, and the apices of the lungs.
Penetrating neck wounds should be approached in respect to the ABCs:
Airway/Breathing: intubate if necessary, but consider basic airway management. BLS adjuncts are an excellent temporizing measure permitting resuscitation before intubation. These patients will have difficult airways. Provide oxygen and ventilate as needed. Remember- can’t intubate, can’t oxygenate = CRIC.
Circulation: direct pressure is key to stop bleeding. If these patients are in shock, it’s most likely due to hemorrhage. That being said, you should still consider tension pneumothorax and decompress if necessary.
Disability/Exposure: A C-collar should only be used if neuro deficits are present. Be sure to visualize the entire neck—remove the collar, if placed prior to your arrival, in order to inspect wounds.
Hospital management will involve stabilization followed by either emergent surgery or CT scan to better visualize anatomy. If the platysma is violated, patients should at a bare minimum be observed for 24 hours.
