56 Neck Trauma
Neck trauma can be rapidly fatal due to bleeding, airway obstruction, pulmonary complications and spinal injury. Because initial assessment and management of a trauma victim may be the keys to a favourable outcome, it is important to exclude conditions that can cause death within minutes by correctly assessing and managing the patient at the trauma scene, during transportation, and on arrival at the emergency unit.
56.1 Initial Management
Initial resuscitation is based on the advanced trauma life support (ATLS) principles with specific attention to the airway, major cervical vessels, C spine and pulmonary complications.
56.1.2 Spinal Protection
Protect the spine with a hard cervical collar and employ spinal precautions until spinal injury has been excluded.
56.1.3 Secure the Airway
• Assess and secure the airway if there is airway obstruction, a rapidly expanding haematoma, massive external bleeding, and in an unconscious patient with a Glasgow coma score of less than or equal to 8.
• Most patients can be safely intubated by rapid-sequence induction and direct laryngoscopy.
• Blind, awake intubation is not advised with penetrating neck wounds when patients are drunk and unruly as deaths have been attributed to blind intubation in such circumstances.
• When endotracheal intubation is not possible, perform a cricothyroidotomy rather than a tracheostomy due to its speed and simplicity, and convert it to a formal tracheostomy to avoid subglottic stenosis only once the patient has been stabilised.
• The trachea may be intubated directly through an open penetrating tracheal wound.
• Take care not to overinflate the cuff of the endotracheal tube above 30 cm H2O to prevent mucosal ischaemia and subsequent tracheal stenosis. Digital palpation to determine balloon pressure is unreliable; therefore, use either a pressure gauge or employ the ‘leak test’. If a patient is to be transported by air, fill the cuff with saline to avoid expansion of the cuff at altitude.
56.1.4 Control Bleeding
• Lay a patient with a penetrating neck wound flat and cover the wound with an occlusive dressing to prevent air embolism.
• Control bleeding with external digital pressure or by inserting a 20-FG Foley urinary catheter into the wound and inflating the balloon with water.
• Should a patient remain hypotensive despite fluid resuscitation, exclude neurogenic shock caused by spinal cord injury.
• Exclude spinal injury with anteroposterior, lateral and open-mouth cervical spine X-rays.
• Prevertebral air and surgical emphysema should raise the possibility of a pharyngeal or oesophageal penetrating injury or a pneumothorax.
• Chest X-ray (anteroposterior [AP] and lateral) is necessary to exclude mediastinal air, a pneumothorax or haemothorax or a widened mediastinum that occurs with intra-thoracic great vessel or oesophageal injury.
• Females of childbearing age must have a pregnancy test done prior to undergoing further radiological examinations.
56.1.6 Define Cervical Injuries
• Avoid probing a wound as this may precipitate major bleeding from a vascular injury.
• Identify entrance and exit gunshot wounds to estimate the likely course of the tract and to predict anatomical structures that might be injured.
• In the absence of an exit wound, locate the bullet with cervical and chest X-rays to determine the course of a tract.
• Note whether saliva, chyle or cerebrospinal fluid is draining from a wound.
• Palpate the neck for surgical emphysema.
• Look for ‘hard signs’ of vascular injury such as bleeding, an expanding haematoma, a pulse deficit (check superficial temporal artery pulses) and auscultate the neck for a bruit.
• Do a neurological examination looking for Horner’s syndrome, and cranial nerve, spinal cord and brachial plexus injuries.
With the patient stabilised, proceed to take a detailed history including questions that might indicate oesophageal, vagal or recurrent laryngeal nerve injury.
56.2 Penetrating Neck Trauma
56.2.1 Zones of Neck
Unlike the cervical levels used with head and neck cancers, trauma surgeons divide the neck into three zones that indicate structures most at risk of injury. Most important vessels and viscera are situated anterior or deep to the sternocleidomastoid muscle.
• Zone I encompasses the base of the neck and extends from the thoracic inlet inferiorly to the cricoid cartilage superiorly. It contains large vessels (subclavian artery and vein, brachiocephalic vein, common carotid artery, aortic arch, internal and external jugular veins), trachea, oesophagus, thyroid, the thoracic duct on the left side and the apex of the lung.
• Zone II encompasses the midsection of the neck and extends from the cricoid cartilage to the angle of the mandible; structures at risk of injury include the carotid and vertebral arteries, internal and external jugular veins, larynx, pharynx, oesophagus, cranial nerves X to XII and sympathetic trunk.
• Zone III extends above the angle of the mandible to the base of the skull and contains the parotid gland, pharynx, internal and external carotid arteries and its branches, internal jugular vein, cranial nerves V, VII, IX to XII and the sympathetic trunk.