NECK  INJURY

Can be classified into penetrating and blunt.

Penetrating Neck Injury

1. Neck is divided into zones:
• zone I - between clavicle and cricoid
• zone II - between cricoid and mandibular angle
• zone III - between mandibular angle and  skull base

Management : 

1. ABC of trauma plus C-spine precautions:
    
• A/B - ETT intubation is the most advocated. Cricothyroidotomy is an alternative if no  hematoma is present. Bag mask ventilation should be limited to minimum since the positive pressure employed  can cause penetration of air into mediastinum and vessels.  Chest xray is to be obtained to r/o pneumothorax.
   
• C - IV must be put on opposite side. Try to keep pt in Trendelenberg if sucking wound is identified in order to decrease air embolism potential.
     
• C-spine part of the  neck with  penetrating trauma, unless directly involved, is rare. Yet pt can have injury to vascular, thecal/dural or nerve structure of the spine.  CT with  myelogram should be obtained.
   
2. Zones:
        
• Zone I ®If pt is stable®  Angiography
  If pt is unstable  O.R.
   
• Zone II ® If pt is stable®   Angio followed  by Esophagogram and Bronchogram. (Some do advocate immediate operative intervention for injuries to this zone.)
  If pt is unstable  O.R.
   
• Zone III ® If pt is stable ® Angio followed by Esophagogram.
  If pt is unstable  O.R.
   
3. Vascular injury - look for:
   
   active bleeding, hematoma, carotid bruit, radial pulse
                                  ¯
   depending if pt's stable or not one of the following:
                                  ¯
                OR , Angio or Color Doppler
    
4. Neurological injury: Penetration can injure spine directly and present with complete dissection  (paraplegia)  or incomplete ® hemisection (motor deficit with controlateral sensory deficit).  Injury also can  occur to carotid vessel with consequent ¯ blood flow to brain.  Injury  to single peripheral nerves can cause damage to following:
    
1. Facial, recurrent laryngeal (hoarseness), accessory (shrugging of shoulder) nerves can be involved.
    
2. Cervical plexus (C1-C4) injury can affect SCM, phrenic, hypoglossal functions.
    
3. cBrachial plexus nerves (C5-T1) injury can affect radial, ulnar, musculoskeletal and other.
    
5. Laryngeal injury - can cause:
   
   respiratory distress, aphonia, sq emphysema, bloody sputum, SOB, PNTX,
   
   hoarseness, pneumomediastinum (Hamman's crunch ), pneumopericardium, stridor
                                                           ¯
   Establish ABC  of  trauma and C-spine precautions
           ¯                                ¯                         ¯
    Neck Xray          Laryngoscope           CT
                                     or
                             Bronchoscope                                                      
   
   Establish Airway as needed with ETT or Cricothyroidotomy
6. Esophageal  injury - can cause:
   
   dysphagia, dyspnea, odynophagia, sq emphysema, pneumomediastinum
   
   ( Hamman's  crunch ), pneumopericardium, PNTX
                             ¯
           Establish  ABC and  C-spine
   
   Neck/Chest Xray ® Esophagogram  with Gastrograffin   Esophagoscopy 
                               ¯
            IVF, Antibiotics, STAT OR
    

Blunt Neck Injury

1. Laryngeal, Esophageal  and Neurological injury remains as above.
    
2. Vascular injury in Blunt trauma can cause:
    
1. Expanding  hematoma, TIA/Stroke symptoms 2ry to carotid vessel dissection.
    
2. One may have no physical findings of trauma and yet dissect vessel by twisting the neck.

Management is guided by clinical findings and Angio or  Surgical intervention.

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