| Zones | Landmarks | Structures/considerations |
|---|---|---|
| I | Defined inferiorly by clavicles and superiorly by the cricoid cartilage | In addition to neck structures (e.g., trachea, esophagus, neck vessels), consider injuries to thoracic structures, i.e., lung, subclavian vessels, common carotid artery, thoracic duct |
| II | Extends from the cricoid cartilage inferiorly to the angle of the mandible superiorly | Easily accessible surgically with ability to obtain proximal and distal control of bleeding. Includes carotid vessels, internal jugular veins, pharynx, esophagus |
| III | Includes the area superior to the angle of the mandible to the base of the skull | In addition to neurovascular injury (e.g., distal carotid, vertebral artery, cranial nerves), consider as a head injury |
Presentation
- In penetrating injuries, it is important to look for hard and soft signs of injury (see Table 9.2).
- Any hard or soft signs are concerning for significant neck trauma.
- Screening guidelines exist to determine the presence of blunt cerebrovascular injury (see Table 9.3).
Table 9.2. Hard and soft signs of injury
| Hard signs | Soft signs |
|---|---|
| Expanding hematoma | Hemoptysis/hematemesis |
| Severe active bleeding | Oropharyngeal blood |
| Shock not responding to fluids | Dyspnea |
| Decreased/absent radial pulse | Dysphonia/dysphagia |
| Vascular bruit/thrill | Subcutaneous/mediastinal air |
| Cerebral ischemia | Chest tube leak |
| Airway obstruction, stridor | Nonexpanding hematoma |
| Air bubbling through wound | Focal neurological deficit (contralateral side) Carotid: sensory or motor deficits, ipsilateral Horner syndrome Vertebral: ataxia, vertigo, emesis, or visual field deficit Carotid–cavernous sinus fistula: orbital pain, decreased vision, diplopia, proptosis, seizures, epistaxis |
| Cervicothoracic seat belt sign |
Table 9.3. 2011 Denver Health Medical Center Blunt Cerebrovascular Injury Screening Guidelines
| Signs/symptoms • Arterial hemorrhage from neck/nose/mouth • Cervical bruit in patient <50 years old • Expanding cervical hematoma • Focal neurological defect (including TIA) • Neurological deficit inconsistent with head CT • Stroke on CT/MRI |
| Risk factors • LeFort II or III mid-face fracture • Mandible fracture • Complex skull fracture, basilar skull fracture/occipital condyle fracture • Diffuse axonal injury and GCS <6 • Cervical subluxation or ligamentous injury/transverse foramen fracture/fracture C1–C3/any body fracture • Near hanging with anoxic brain injury • Clothesline injury or seat belt abrasion with altered mental status/significant swelling/pain • Traumatic brain injury with thoracic injuries • Scalp degloving • Thoracic vascular injuries • Blunt cardiac rupture |
Diagnosis and evaluation
- High-resolution CT-angiography (CTA) is the initial diagnostic study of choice in the stable patient with penetrating neck trauma or blunt neck trauma when blunt cerebrovascular injury is suspected.
- CTA can be the initial diagnostic study of choice regardless of zone of injury.
- CTA is particularly useful for zone I and III penetrating injuries, which are more difficult to evaluate by physical examination.
- CTA can be the initial diagnostic study of choice regardless of zone of injury.
- Historically, stable, symptomatic patients with zone II penetrating injury required mandatory exploration but with the capabilities of CTA, there has been a paradigm shift and selective exploration is recommended.
- Injuries can be categorized into laryngotracheal (airway), pharyngoesophageal (digestive tract), and vascular.
1. Laryngotracheal:
• Symptoms include hoarseness, dyspnea, stridor, subcutaneous air, hemoptysis, and tenderness of the laryngeal area.Related posts:
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