Concerning signs for emergent surgical intervention include progressive subcutaneous or mediastinal emphysema, pneumothorax, severe dyspnea, or associated esophageal trauma. Once the airway is secured, other injuries to the larynx or trachea are usually treated surgically in the OR. Time is of the essence, especially if there is an expanding hematoma in the neck that will soon obstruct your anatomy. If orotracheal or fiberoptic intubation is unsuccessful, be prepared to move quickly to the surgical airway. However, fiberoptic nasotracheal intubation is acceptable if the airway physician is proficient in that technique. Avoid traditional nasotracheal intubation, as it is a “blind” procedure. RSI has been shown to be quite successful in these patients.įiberoptic intubation can be considered if a skilled operator is present and the equipment is readily available. Direct laryngoscopy is optimal, with orotracheal intubation the method of choice. If in doubt, intubate early – and consider the prophylactic intubation if you anticipate decompensation. A skilled operator should be intubating these patients, as the airway will only become more difficult to secure with time (and with repeat attempts). Furthermore, these patients have a propensity to develop pulmonary edema and ARDS. In near-hanging or strangulation victims, you should maintain a very low threshold for intubation. ![]() Physical signs that warrant immediate airway management include stridor, respiratory distress, shock, or rapidly expanding hematoma. We will concentrate on the specific injuries seen in neck trauma that are often encountered, including those easily missed. Start with your ABCs while following ATLS guidelines, as in any trauma situation, with surgical consult at the bedside. Per Rosen’s, hard and soft signs are as follows: “Soft” signs indicate close observation and reevaluation, though not necessarily surgical intervention. surgical consult and operative intervention. “Hard” signs indicate the need for emergent management, i.e. Stable patients should be evaluated for “hard” and “soft” signs. The major issue with blunt trauma of the neck is in missed or delayed diagnosis. The majority of blunt neck trauma is from MVCs, as well as assault and strangulation. Stab wounds and lower-velocity GSW cause a 50% lower incidence of clinically significant lesions.īlunt neck trauma is even more uncommon than penetrating neck trauma. The major mechanisms are GSW, stab wounds, and shrapnel. The incidence of penetrating neck trauma is 0.55-5% of all traumatic injuries. However, Zone II injuries also have the best prognosis because there’s a larger areas of exposure, allowing for easier proximal and distal control. Zone II is the most exposed zone, and is consequently the most likely to be injured. Zones I and III are difficult to access and to manage in the operating room, with Zone I injuries at the highest risk. The struggle with neck trauma lies in the different zones of the neck. Zone III (upper neck) – above the angle of the mandible: distal carotid artery, vertebral artery, distal jugular vein, salivary/parotid glands, CNs 9-12 Zone II (mid-neck) – from the cricoid cartilage to the angle of the mandible: carotid/vertebral artery, larynx, trachea, esophagus, jugular vein, vagus and recurrent laryngeal nerves Zone I (base of neck) – below the cricoid cartilage (to the sternal notch): mediastinal structures, thoracic duct, proximal carotid artery, vertebral/subclavian artery, trachea, lung, esophagus ![]() The neck is divided into 3 Zones, which become important in evaluating and managing these patients, especially with regard to the structures lying within each division. Neck trauma can be split into penetrating injury and blunt injury. Oftentimes, the neck trauma patient may appear stable, only to have delayed injury found later, causing increased morbidity and mortality. Concern for vascular, neurologic, digestive tract, and airway injury are of paramount importance in the evaluation of these patients, as all can be life-threatening. The neck is a particularly tricky area of assessment and management in the trauma patient, as it is the location for many vital structures. ![]() ![]() Author: Amaan Siddiqi, MD (Senior EM Resident, Brooklyn Hospital Center) // Edited by: Alex Koyfman, MD and Justin Bright, MD
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