Trauma Guideline Manual - SUNY Upstate Medical University

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86____________ Trauma Guideline ManualUpstate Medial University Trauma CenterPRACTICE GUIDELINES: MANAGEMENT OF PENETRATING NECK INJURIESOBJECTIVE:Provide guidelines for the management of a penetrating injury to the neck, specifically as itrelates to the need for operative exploration and the ordering of diagnostic studies.DEFINITIONS:Penetrating Injury: Any inflicted injury that penetrates the skin. This could be a gunshot wound,stab wound or foreign body penetration of any nature. These guidelines do not apply topenetration of the oral or pharyngeal mucosa as might be seen with medical instrumentation,etc.Neck: The circumferential region of the body bounded by the clavicles and the base of theskull.GUIDELINES:1. For all penetrating injuries of the neck, first apply all of the principals of ATLS (see“Prioritization Guidelines”). Pay particular attention to airway, since this will be the most lifethreateningassociated condition.2. NOTE: EARLY intubation is key. Emergency cricothyrotomy or tracheostomy may becomplicated by release of contained hematoma with potentially disastrous consequences.Proceed only in extremis!3. If the neck injury is associated with any of the following conditions, then the patient shouldbe taken immediately to the operating room for exploration:a. Shock.b. Active hemorrhage.c. Expanding hematoma.d. Zone II penetrating injury (thru the platysma)e. Need for surgical airway.f. Obvious esophageal injury.g. Obvious tracheal injury.4. For stable neck injuries, a determination should be made as to whether the platysma hasbeen penetrated. Slash wounds can easily be examined to determine this. Usually slashwounds can be fully explored and closed in the ED if there are no majory injuries. Forpuncture wounds that seem superficial, the wound can be anesthetized and enlarged for adirect visual observation to determine if the platysma is intact. If the platysma is intact, thenclose the wound if possible and discharge.5. If the platysma has been violated, then classify the wound as:( see diagram)a. Zone I – below cricoid cartilage.b. Zone II – between cricoid and angle of the mandible.c. Zone III – above the angle of the mandible.d. An X-ray of the neck may be helpful if a bullet or foreign body is still in the neck
Trauma Guideline Manual______________Upstate Medical University Trauma Center876. For STABLE Zone I injuries (which are really chest injuries):a. Obtain a chest X-ray to determine the presence of chest injury.i. Obtain an angiogram or CTA, including the aortic arch and the great vessels.ii.Obtain an esophagram. (Gastrograffin and if no defined leak proceed to thinbarium for better definition)iii. Obtain or perform bronchoscopy.b. Obtain CT scan to determine track of bulletc. If track approaches vessels or airway, then will need an angiogram and bronchoscopyd. Treat on the basis of the findings.7. For a Zone II injury, use clinical findings to classify as low probability of vascular andaerodigestive injury or high probability of vascular and aerodigestive injury.a. For high probability injuries (GSW, shotgun wounds, swelling, path crossing midline):i. If the injury is a gunshot wound or a shotgun injury, consider a CT angiogram tohelp define extent and location of vascular injury if the patient is stable. In manycases this step is skipped since vascular injury is likely.ii. Prophylaxis with antibiotics.iii. Take to the operating room for neck exploration.b. For low probability injuries (stab wounds, minimal swelling, lateral, posterior). ObtainCTA scan and look for injuries to vital structures. If found and obvious then explore,otherwise:i. Obtain esophagram.ii. Perform laryngoscopy and bronchoscopy if indicated (e.g., air in tissues orsubcutaneous emphysema).iii. Treat based on the findings.8. For Stable Zone III injuries:a. Obtain angiogram.b. Obtain or perform direct pharyngoscopy and laryngoscopy.c. Treat based on findings.9. For GSW injuries (usually Zone II) that appear to have traversed the neck lateral to thecarotid sheath, a CT scan (with contrast) can define the bullet track. The proximity to thevessels and aerodigestive organs can be determined as an indicator for any additionalstudies (see above).10. For all penetrating neck injuries that have violated oral mucosa, treat with antibiotics(usually penicillin, penicillin/aminoglycoside or clindamycin).
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Trauma Guideline Manual - SUNY Upstate Medical University

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