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.
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
Structures not in the neck can be involved depending on trajectory of wound
Zone 1 wounds are most likely to involve thoracic structures
Zones of the neck:
Evaluate penetrating neck wounds by system
Subjective: shortness of breath
Objective: work of breathing, asymmetric lung sounds, stridor, crepitus
If present, hypotension/tachycardia are most likely due to hemorrhagic shock
Expanding hematoma to neck
Also consider possibility of tension pneumothorax and cardiac tamponade
Consider neurogenic shock if not responding to fluids
Evaluate for neuro deficits
Take note of the zone(s) of the wound and report to receiving facility
Airway and Breathing
First order of business in penetrating neck wounds
“Airway” does not mean “intubate.” BLS options may provide an excellent temporizing measure. These patients are likely to have very difficult airways.
Consider intubation patients who can’t manage their own airway: snoring, gurgling, poorly controlled secretions, persistent hypoxia
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
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
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
Expectant management: 35% mortality
Zone 1 = imaging
Zone 2 = surgical exploration
Zone 3 = imaging
Modern approach: “no zone”
“Hard signs” = OR emergently for surgical exploration
Expanding hematoma or severe hemorrhage
Thrills or bruits
Absent radial pulse
Air bubbling from wound
Massive hemoptysis or respiratory distress
Soft signs = Imaging (CT angiography) to guide management
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.
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.