Approach to penetrating neck injury: Clinical sciences

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Introduction 0:00–1:27

Penetrating neck injuries typically occur from stab or gunshot wounds and can be life-threatening depending on the location.
Now, the neck is divided into three zones which contain vital structures. Zone I extends from the sternal notch, to the cricoid cartilage.
It contains the subclavian vessels, proximal carotid arteries, vertebral arteries, internal jugular veins, trachea, Thyroid gland, esophagus, apices of the lung, thoracic duct, spinal cord, and brachial plexus.
Zone II extends from the cricoid cartilage, to the angle of the mandible. It contains the common carotid arteries and their branches, vertebral arteries, jugular veins, larynx, pharynx, trachea, esophagus, spinal cord, vagus nerves, and recurrent laryngeal nerves.
Finally, zone III extends from the angle of the mandible, to the base of the skull. It contains the distal internal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, and cranial nerves IX through XII.
Your first step when evaluating a patient with a penetrating neck injury is to perform a primary survey by assessing their ABCDE.

Acute Management 1:27–2:53

Because any neck injuries can compromise the airway, it's important to secure the airway as soon as possible. Make sure to stabilize the cervical spine with a C-collar and always have a low threshold for endotracheal intubation.
Keep in mind that intubation should be performed carefully to avoid causing further damage. Now, if there is a laryngeal obstruction or exposed trachea, proceed with a surgical airway like a cricothyroidotomy.
Once the airway is secured, ensure adequate ventilation by providing supplemental oxygen. Next, obtain two large bore IVs or an intraosseous line if intravenous access cannot be obtained.
Continuously monitor vitals while starting appropriate resuscitative measures including blood transfusions. Then, assess for disability by performing a neurological assessment and calculating the Glasgow Coma Scale, and perform the pupil exam as well.
Then lay the patient on a flat board for spine immobilization. Finally, expose the patient by removing all clothing and bandages to ensure no injuries are missed.
After examining the patient, place a warm blanket over them to avoid hypothermia. Now that we’ve finished acute management, let's look at unstable patients.

Unstable Patient 2:53–4:56

If your patient is unstable, quickly perform a secondary survey. This includes a focused head-to-toe physical exam assessing for any “hard” signs of penetrating neck injury.
Examples include rapidly expanding or pulsatile hematoma, severe arterial bleeding, decreased or absent pulses, massive hemoptysis, massive hematemesis, respiratory distress, air bubbling from the wound, the presence of a thrill or bruit, or focal neurologic deficit.
These signs indicate the presence of severe injury to vital structures within the neck that require immediate surgical intervention.
There are two major types of injuries to look for in an unstable patient: vascular injuries or aerodigestive tract injuries.
Let’s begin with vascular injuries. In major vascular injury, history often reveals high-force trauma like a stab or gunshot wound.
On physical examination, you might find absent pulses, or the presence of a thrill or bruit, active or pulsatile bleeding, a pulsatile or expanding hematoma, or focal neurologic deficit.
You might also see signs of hemorrhagic shock like hypotension refractory to appropriate fluid resuscitation. With these findings, you can diagnose an unstable vascular injury that requires emergent surgical intervention.
When it comes to aerodigestive tract injuries, they also result from stab or gunshot wounds. Physical exam usually reveals hemoptysis, hematemesis, or respiratory distress, as well as air bubbling from the neck wound, or palpable crepitus.
If you see these findings, you are dealing with an aerodigestive tract injury. These patients should go immediately to the operating room.
Okay, now that the life-threatening conditions are taken care of, let’s talk about stable patients. As before, your next step is to perform a complete secondary survey.

Stable Patient 4:56–5:41

However, in this case, you are assessing for “soft” signs of injury like non-expanding hematoma, minor hemoptysis or minor hematemesis, dysphonia, dysphagia, tachypnea, or subcutaneous emphysema or mediastinal emphysema.
These signs indicate injury to vital structures, so before any operative intervention, you need to order some tests, depending on which anatomic zone of the neck is injured.
Alright, your exam might show zone I injuries. As a reminder, this means the area from the sternal notch to the cricoid cartilage.

Stable Zone I Neck Injury 5:41–7:18

You might also find a non-expanding hematoma, minor hemoptysis, minor hematemesis, dysphonia, dysphagia, tachypnea, or subcutaneous emphysema.
If you see these, you should order a CTA of the chest and neck. Now, if the CTA shows a pneumomediastinum, an aerodigestive tract injury is suspected.
A follow-up swallow esophagram and flexible bronchoscopy should be performed. If the swallow esophagram shows contrast extravasation, but the flexible bronchoscopy is normal, then you are dealing with esophageal injury.
This requires urgent surgical intervention for wide local drainage. On the other hand, a normal swallow esophagram with a flexible bronchoscopy showing evidence of injury to the airway confirms a tracheal injury.
This is also managed by operative repair. Let’s go back to the CTA.
If it shows active extravasation or blush from vascular structures contained within the neck, that’s vascular injury. Depending on the location of the extravasation, you can make your diagnosis of a subclavian artery, internal jugular vein, carotid artery, or vertebral artery injury.
These injuries require urgent surgical or endovascular repair to stop the bleeding. Okay, let’s move on to zone II neck injuries.

Stable Zone II Neck Injury 7:18–9:17

On exam, you can expect to see an injury between the cricoid cartilage and the angle of the mandible. Additionally, you might find a non-expanding hematoma, subcutaneous emphysema, hoarseness, dysphagia, dysphonia, or neurologic deficits.
Now, if patients are symptomatic, suspect a vascular or an aerodigestive tract injury. These patients require urgent operative exploration and repair of any found injuries.
On the flip side, some patients with zone II neck injuries might be asymptomatic. In the case of asymptomatic patients, order a CTA of the neck, as well as a triple endoscopy, which includes a direct laryngoscopy, flexible bronchoscopy, and upper endoscopy.
If the CTA of the neck shows a pneumomediastinum, and upper endoscopy shows esophageal injury, but flexible bronchoscopy and direct laryngoscopy are normal, you can diagnose cervical esophageal injury.
The management is an urgent surgical intervention and possibly wide local drainage. Next, if CTA shows pneumomediastinum, but the upper endoscopy is normal, while flexible bronchoscopy or direct laryngoscopy show airway injury, Then you are dealing with airway injury.
This is also treated by operative repair. Lastly, if you see active extravasation or blush from vascular structures on the CTA, but triple endoscopy is normal, that’s vascular injury.
On the CTA you will be able to determine which structure is injured based on the anatomy. It will most likely be a subclavian artery, internal jugular vein, carotid artery, or vertebral artery injury.
These injuries are managed by urgent surgical or endovascular repair. Finally, let’s talk about zone III injuries.

Stable Zone III Neck Injury 9:17–10:55

Keep in mind that zone III of the neck extends from the angle of the mandible to the base of the skull. On exam, you will find an injury in that area in addition to a non-expanding hematoma, cerebrovascular accident symptoms, tongue deviation, hoarseness, or dysphagia.
Your next step is to order a CTA of the neck and head to assess for injuries to vital structures. Now, if the CTA shows a pneumomediastinum, you should suspect an aerodigestive tract injury.
Then obtain a swallow esophagram and flexible bronchoscopy to complete your workup. You can expect the esophagram to show contrast extravasation but the flexible bronchoscopy to be normal.
These findings indicate an upper esophageal injury and/or pharyngeal injury. Urgent surgical intervention with repair and wide drainage is the treatment of choice.
On the other hand, if you see a normal esophagram, but the flexible bronchoscopy shows evidence of injury to the airway, you can make your diagnosis of airway injury.
This is also managed by operative repair. Now, let’s go back to the CTA and discuss our final finding.
If the CTA shows active extravasation or blush from vascular structures within the neck, you are dealing with a vascular injury.
Based on anatomy, you can make your diagnosis of an internal jugular vein, carotid artery, or vertebral artery injury. Again, these injuries are managed by urgent surgical repair.
Alright, as a quick recap… In an unstable patient with a penetrating neck injury, look for “hard” signs of vascular and aerodigestive tract injuries, that require immediate operative intervention.

Review 10:55–11:28

In a stable patient, you should look for “soft” signs of injury and order adjunctive tests like CTA, flexible bronchoscopy, direct laryngoscopy, upper endoscopy, and swallow esophagram.
Common injuries include vascular, tracheal, and pharyngeal injuries, and esophageal injuries which may occur