Dr ABDELMONIEM SAEED

Introduction
The management of patients with blunt or penetrating
neck injuries can be challenging.

The neck contains a high concentration of vascular,

autodigestive, and spinal structures in a relatively
confined space.

Symptoms of injuries to structures such as the esophagus

can be subtle or delayed in presentation
Triangles of the neck.
.
Fascial layers of the neck.

Clinical presentation
Signs and Symptoms of Neck Injury
Hard Signs Soft Signs
Hypotension in ED Hypotension in field
Active arterial bleeding History of arterial bleeding
Diminished carotid pulse Unexplained bradycardia
Expanding hematoma Apical capping on chest
Hemothorax >1000 mL radiograph
Thrill/bruit Stridor
Lateralizing signs Hoarseness
Air or bubbling in wound Vocal cord paralysis
Zones of the Neck
The most widely used classification is that of
Roon and Christensen.
 Zone I extends from the clavicles to the
cricoid cartilage.
 Zone II extends from the inferior margin of
the cricoid cartilage cephalad to the angle of
the mandible.
Zone III is located between the angle of the
mandible and the base of the skull.
Zones of the neck
Zone I Injuries
Evaluation of zone I is directed at identifying
injuries to the upper thorax.

The lungs, trachea, esophagus, spine, vertebral

and proximal carotid arteries, and major thoracic
vessels are all at risk for injury.

A portable chest radiograph can identify a

significant pneumothorax or hemothorax.
Zone II Injuries
Penetrating trauma to zone II risks injury to
the carotid and vertebral arteries,
 jugular veins.
Esophagus.
Spine.
larynx, and trachea.

Operative challenges in zones I and III are usually not

encountered in zone II.
Zone III Injuries

The distal carotid and vertebral arteries, pharynx, and

spine are all at risk.

Evaluation for vascular injury is of primary concern.

 As in zone I, evaluation of zone III injuries is

generally by selective, nonoperative management.
Organ System Classification
Vascular ( most common )
Pharyngoesophageal
Laryngotracheal
Others ( cranial nerve, thoracic duct, brachial plexus,
spinal cord….
Vascular Evaluation of Penetrating Neck Trauma
Mxt
ABCD approach
Proper examination and management of the wound

If the platysma has been violated, it must be assumed that

significant injury has occurred immediate surgical
consultation is indicated.

 Never probe neck wounds beneath the platysma because

this maneuver may disrupt hemostasis
 Airway :
Clinical Factors Indicating Need for Aggressive
Airway Management
 Acute respiratory distress

Airway obstruction from blood or secretions

Massive subcutaneous emphysema of the neck

Tracheal shift

Alteration in mental status

 Expanding neck hematoma

Breathing
Administer high-flow oxygen and provide continuous
monitoring by pulse oximetry.

Unequal breath sounds and asymmetric chest

movement are signs of inadequate ventilation.

These signs are associated with a neumothorax,

hemothorax, or tension pneumothorax.
Circulation

Do not clamp bleeding vessels because

subsequent injury to vascular or nervous
structures may result.

Avoid placing IV access at a location where the IV

fluid would flow toward the site of injury.
Algorithm for management of penetrating neck injuries