Initial management of blunt and penetrating neck trauma

Abstract

Learning objectivesBy reading this article you should be able to:Recall the key features that may indicate impending airway obstruction in a patient with acute neck trauma. Explain the principles of managing a patient with a threatened airway resulting from neck trauma. Distinguish the key features of the Advanced Trauma Life Support (ATLS) primary survey that are pertinent to patients with acute neck trauma. Outline the next steps in management of acute neck trauma after completing the primary survey and securing the airway.As a narrow conduit for the major blood vessels, aerodigestive tract, and neurological structures passing between the head and the torso, the neck is an especially hazardous area for traumatic injuries. Injuries in this area can be complex to manage, and airway management maybe particularly perilous.Common causes of neck trauma include road traffic collisions (RTCs), sporting injuries, and interpersonal violence. Sadly, interpersonal violence is a global problem. Whilst reported rates are highest in South Africa, Central and South America, the incidence of interpersonal violence rates is increasing in Europe. 1,2 In the year ending March 2019, there were approximately 47,000 offences involving a knife or sharp object in England and Wales; the highest number since comparable data have been recorded (March 2011). 3 It is becoming increasingly likely that anaesthetists, as part of James Shilston FRCA FFICM is a dual trainee in anaesthesia and intensive care medicine in the East Midlands, UK.David L Evans FRCA is an RAF consultant anaesthetist at Nottingham University Hospitals NHS Trust, which is a regional major trauma centre covering a population of around 4 million people. He also provides military medical support to multiple theatres of conflict including Afghanistan. Anthony Simons FRCS-ORL HNS is a consultant head and neck surgeon based at Nottingham University Hospitals NHS Trust who has an interest in airway and head and neck oncologyDavid A Evans FRCA is a consultant anaesthetist at Nottingham University Hospitals NHS Trust with interests in major trauma and head and neck anaesthesia Key pointsThe management of blunt and penetrating neck trauma can be complex and frequently requires close collaboration between anaesthesia and surgical teams. Adherence to Advanced Trauma Life Support (ATLS) principles is fundamental, with an emphasis on early assessment of the airway.The key principles of airway management are to identify any airway injuries and where possible ensure that the tip of the tracheal tube is positioned distal to the site of the injury without causing further airway trauma. If airway injury is suspected, the best ways to secure the airway in a cooperative patient are by awake fibreoptic intubation or awake surgical tracheostomy under local anaesthesia. Severe injuries require immediate surgical exploration. In less emergent situations CT scanning plays a valuable role in planning appropriate further management.

Airway Management for Penetrating Neck Trauma: A Case Report

“…This topographical division helps in anticipating potential injuries and possible need for urgent airway management. Due to the abundance of vascular structures and proximity to the thoracic cavity of zone 1, the wounds presenting in this area have the highest associated mortality [ 9 ]. Wounds in the anterior and lateral aspects of the neck compromise the airway more often than those in the posterior region.…”

“…Also, there is no strong correlation between anatomical site of lesion and clinical presentation. However, the severity of injury is expected to be higher if a patient complains of hemoptysis and stridor at presentation [ 9 ]. Our patient presented with aphonia and a lateral cervical open wound in zone 1 with no sign of a compromised airway.…”

“…Our patient presented with aphonia and a lateral cervical open wound in zone 1 with no sign of a compromised airway. He was submitted to a CT scan to identify the extent and location of airway injury; since it is the recommended initial work-up investigation in patients showing penetrating neck injuries and clinical stability [ 9 ]. Previous planning of airway management is essential and can be aided by routine airway assessment as well as cervical CT.…”

“…Accumulation of air in the tissues may produce progressively greater surgical emphysema which can ultimately produce airway compromise. Anesthetic induction with some intravenous hypnotics and neuromuscular relaxants presents additional risk of apnea and complete collapse of airway, which could previously be deceptively considered safe due to the muscle tone of surrounding neck structures [ 3 , 9 ]. Therefore, maintenance of spontaneous breathing should be sought until securing the airway.…”

“…Blindly placing a tracheal tube or bougie distal to the vocal cords can create a false passage by accidentally dislodging damaged tissues and such devices may even exit the trachea through an anatomical defect caused by the trauma. If a false tract is posteriorly submitted to positive ventilatory pressure the neck anatomy can be perilously distorted with possible complete obstruction of the airway [ 9 ]. Thus, visualization of the anatomy until the tracheal tube is distal to the level of breach is recommended.…”