French Revolution Style

An accident won’t arrive with a bell on its neck.

Finnish Proverb

Welcome back guys…

Today we will talk about a particular form of trauma that most general surgeons fear… The neck trauma…

But, why all this concern?!… Well, first, the neck is a particular anatomical region, usually managed by vascular surgeons and ENT (i.e. ear, nose & throat) doctors (aka otolaryngologists). Secondly, it contains many delicate structures… in particular, vessels and nerves!

You know in the movies when a guy slices the throat of a “good Christian”?! There’s blood squirting everywhere… That’s basically the main reason why neck trauma is so feared…

By the way, as you well know, trauma may be either penetrating or blunt… And the same happens for the neck… To avoid confusion, we are going to talk about penetrating trauma alone, though…

In this post, we will focus on the initial management of patients with neck trauma, and we will scratch the surface of how to treat specific neck injuries…

However, before beginning with our digression, let’s start with a clinical case…

You are strangely on-call when the EMS calls you alerting they are taking in a stabbed man.

You rush to the ER just in time to see the patient brought in:

A – Male, 21 yo;
T – About an hour ago;
M – Penetrating trauma to the neck (pt stabbed during a fight outside a pub);
I – 4 cm stab wound to the right latero-cervical region, actively bleeding;
S – BP 90/60 mmHg, HR 115 bpm, Sat 96% in room air, Temp 36.3 °C;
T – Mildly compressing wound dressing, 500 mL Ringer IV.

On the primary survey:

A – Patent, no cervical pain;
B – Normal breathing sounds, RR 18, Sat 97% in room air;
C – Single linear neck wound actively bleeding, BP 90/60 mmHg, HR 112 bpm;
D – GCS 14/15, PEARL, no neurological signs;
E – No other wounds, log-roll negative.

E-FAST – Negative.
CXR – Negative.

What to do now? How to manage this patient?

Neck Anatomy

This introduction is to briefly review the anatomy of the neck.

We will not discuss it in detail, but we just want to express some simple concepts that may help in understanding the following sections on the patients’ management.

The neck may be grossly divided into two aspects: the anterior and the posterior.

The posterior aspect includes the cervical spine (i.e. bones, medulla, ligaments, etc…), whereas the anterior aspect encloses many noble structures, such as upper airways, arteries, veins, upper gastrointestinal tract, etc…

The anterior aspect may be further divided by the sternal bundle of the sternocleidomastoid muscle into two triangles: the anterior and the posterior triangle. Obviously, this division refers to each side (i.e. right and left). The posterior triangle contains the external jugular vein and the cutaneous branches of the cervical plexus. The anterior triangle is the far more interesting area of the neck though, containing most of the noble and fearsome structures.

One of the most important structures of the neck is the platysma. It is a thin muscular layer surrounding superficially the anterior neck and it forms the so-called superficial fascia. All the noble anatomical structures lie underneath this fascia, and that’s what makes it so important.

Now… Let’s take a look at the anatomical structures hiding inside our necks:

• Midline
  • Upper airways – the larynx and the trachea;
  • Upper gastrointestinal tract – the pharynx and the esophagus;
  • Thyroid and parathyroid glands
• Lateral
  • Vessels
    • Carotid arteries – the common carotid artery (CCA) stays inside the carotid sheath and it is medial to the internal jugular vein; it divides into the internal (ICA) and the external carotid arteries (ECA): the first one is more posterior and enters the basicranium, bringing blood to the brain, while the second one runs more anterior and gives branches to the structures of the external head. Remember that the ICA does not give branches before entering the skull;
    • Internal jugular veins (IJV) – lie within the carotid sheath, lateral to the CCA;
  • Nerves
    • Vagus nerve – it runs inside the carotid sheath, behind and between the CCA and the IJV;
    • Hypoglossal nerve – it reflects and curves upward just above the CCA bifurcation;
    • Phrenic nerve – it runs behind the carotid sheath;
    • Sympathetic trunk – it lies behind and medial to the carotid sheath.

Before approaching the real deal, a brief review of the main neck muscles is mandatory. The neck muscles are important for two reasons: they are crucial landmarks and may guide you during surgery, and they can be used to repair, reinforce and reconstruct particular injuries (e.g. esophageal injuries…).

The sternal bundle of the sternocleidomastoid muscle borders laterally the anterior triangle. Medially, the strap muscles (medial to lateral: sternohyoid m., the superior belly of the omohyoid m., thyrohyoid m.) protect the larynx and the trachea. The omohyoid muscle, posterior to the sternal bundle of the sternocleidomastoid muscle, gives its inferior belly that runs latero-posteriorly toward the scapula.

Introduction

Ok, then… Now that we have introduced the basic anatomy of the neck, we can start talking about neck trauma, and, particularly, penetrating trauma. However, before going into it, there is one more anatomical feature to discuss: the so-called “neck zones”.

The anterior triangle of the neck can be divided into three zones, which helps in determining the possible structures injured according to where the wound lies.

These three zones are:

Initial Management

Patients referring to the hospital after having sustained a neck trauma must be managed at first as every other traumatized patient: following the ATLS protocol. In this specific category of trauma, the initial evaluation must be very accurate, because neck trauma may cause injuries related to each one of the primary survey points.

To make things more clear:

• A – injury to the upper airways and/or to the cervical spine;
• B – hemo-pneumothorax;
• C – hemorrhage (venous and/or arterial bleeding, thoracic and/or cervical);
• D – air embolism, ischemic brain injury;
• E – upper gastrointestinal injury.

Provided the multitude of possible life-threatening injuries that may originate from neck trauma, all the signs suggestive of the presence of these injuries gave birth to the so-called “hard signs”, which are:

• Airway compromise (stridor, hoarseness, hematemesis…);
• Massive subcutaneous emphysema and/or air bubbling through the wound;
• Bruit or palpable thrill;
• Expanding or pulsatile hematoma;
• Active bleeding;
• Shock;
• Unilateral pulse deficit;
• Neurologic deficit.

As we have already stated in our previous post on “rapid sequence intubation”, remember not to use muscle relaxants in a patient with unstable airways or actively bleeding hematoma to the neck! These drugs will relax the neck muscles, destabilizing the trachea even more and/or letting the hematoma rapidly expand, thus compromising the intubation! You would not find yourself in a “cannot intubate, cannot ventilate” situation…

The presence of at least one of these “hard signs” warrants immediate surgical exploration.

In the case of active bleeding, temporary measures to stop the bleeding must be taken:

• Compressive dressing passing the bandage under the contralateral armpit;
• Insert a clamped urinary catheter and inflate its balloon with water/saline, suture the wound above if necessary;
• Airtight dressing and Trendelemburg position to prevent air embolism.

So then… We have stated that patients with neck trauma and at least one “hard sign” are good candidates for immediate surgical exploration. In this case, the neck zone involved in the trauma may be of some help in deciding the most appropriate surgical incision to perform:

• Zone 1 – median sternotomy;
• Zone 2 – transverse cervical collar or anterior sternocleidomastoid incision;
• Zone 3 – anterior sternocleidomastoid incision with/without mandible resection/dislocation.

However, on the other hand, if the patient involved has no “hard signs” and is hemodynamically normal, an accurate (and delicate) wound exploration must be achieved. The main goal is to determine the grade of involvement of the platysma muscle and the wound trajectory.

If the platysma is not violated (i.e. the wound is superficial and does not penetrate deeper to it), the patient may be treated with local wound care alone. Otherwise, if the platysma is involved in the trauma, the risk of injuries to the underneath structures is quite high, and the patient must be managed accordingly.

Once, the following management was determined by the neck zone involved in the trauma, and each zone has a different diagnostic pathway, depending on the structures at higher risk. However, nowadays, thanks to the more and more spreading of CT scans, the so-called “no-zone” approach has replaced the old protocol. In fact, the multi-detector CT angiography (CTA) of the neck and the chest has high sensibility and specificity to find many different injuries caused by this kind of trauma, replacing most of the old methods.

Therefore, patients with platysma violations and no “hard signs” should be addressed to a CTA. Similarly, patients with “hard signs” who are not in a shock (e.g. pts with active bleeding successfully managed with temporary measures and active resuscitation, pts with a pneumothorax and an ICD in place…) may be taken to perform a CTA of the neck and the chest.

Obtaining a complete and detailed preoperative representation of the injuries sustained by the patient allows you to decide whether surgery is actually the best choice, or if there are other better options to treat him/her.

Remember that even if the first approach to the traumatized patient is operative, he/she should undergo a CTA postoperatively, as soon as his/her hemodynamic status is stable enough.

Specific Treatments

Ok… We have seen how to initially manage a patient with penetrating neck trauma. Now, let’s try to go a little bit deeper, focusing on how to treat the different specific neck injuries…

1. Vascular Injury

Bleeding is usually coming from deep inside the wound (the platysma is thin, and it does not bleed too much), and the cause may be an injury to the internal jugular vein, one of the carotid arteries, or a mix of the two.

As we have seen before, an actively bleeding patient needs immediate bleeding control, and this can have two possible results:

• The hemorrhage is successfully managed by the maneuver: the patient should undergo a cervical-thoracic CTA. If the CTA reports a venous injury (i.e. internal jugular vein), the patient may be managed conservatively. For example, if the urinary catheter was used to stop the bleeding, it can be left in place for 48 hours, and then safely removed (in 2 days the clot is stable enough). If the CTA shows an arterial injury, the patient must undergo operative management, either angiographic and/or surgical.
• The bleeding does not stop: the patient must be brought to the OR for an emergency neck exploration.

The surgical approach to neck vascular injuries is basically the same as for all vascular injuries: proximal and distal control at first, then dealing with the problem.

Depending on the extension of the damage, carotid injuries may be treated with primary repair, patch, or graft.

Systemic heparinization (100 U/kg) may be required in the case the repair is complex (e.g. end-to-end anastomosis, interposition graft…).

The primary repair is achieved using a 6-0 polypropylene suture. Before tying the last knot, the presence of an appropriate back-bleeding from the ICA and the ECA must be checked. This allows to clean off the arteries from any residual trace of debris. After that, the repair should be flooded with a heparinized solution. The flow must be restored, following the order: externally, into the ECA, and, at last, into the ICA. This precise sequence drastically reduces the risk of embolism.

Deeper bleeding from a vertebral artery is really difficult to address because it lies within the transverse foramen. An attempt in repairing the injury may very likely end up with additional injury and complications. A simple and useful alternative that usually allows rapid control of the hemorrhage is to press bone wax into the area of bleeding.

2. Upper Gastrointestinal Injury

Pharyngeal injuries are usually treated successfully with just nonoperative management, meaning:

• Nil per Os (NPO);
• Nasogastric tube (NGT) and enteral nutrition for 7-14 days;
• IV antibiotics.

After 7-14 days, an endoscopy and/or a contrast swallow imaging study should be performed before restoring the normal diet to check the complete healing of the injury.

More complex is the management of esophageal injuries. In this setting, the degree of tissue loss and/or necrosis of the esophageal wall is a determinant factor to decide the best management:

• No significant tissue loss/necrosis – primary repair (2 layers of suture (i.e. mucosa and muscular) with a possible reinforcement (i.e. strap or sternocleidomastoid m. if cervical; parietal pleura, pericardium or intercostal m. if thoracic; diaphragm or stomach if thoracoabdominal);
• Significant tissue loss/necrosis – cervical esophagostomy, drain gastrostomy, feeding jejunostomy.

Obviously, the patient must be kept NPO, and IV antibiotics must be administered. In the case of primary repair, an NGT should be positioned to protect the repair and administer enteral nutrition.

3. Upper Airways Injury

Laryngeal injuries are quite peculiar, and we will not discuss them extensively here. However, we want to give you just a couple of pieces of information.

The thyroid cartilage is the laryngeal structure most commonly involved.

Except for minor injuries (i.e. small endolaryngeal hematoma without signs of fractures and good airway patency), all other damages require at least a tracheotomy. Conservative treatment includes the use of proton pump inhibitors, steroids, and humidity, together with close observation.

If the injured laryngeal cartilage is not exposed and the fracture is nondisplaced, repair may be avoided. In all other cases, fixation should be performed within 24 hours to keep the risk of scarring low. The repair can be achieved with stainless steel or absorbable/non-absorbable suture. The use of a stent is indicated if the larynx is still unstable after fixation or if the laceration involves the anterior commissure. The stent should be removed after 10-14 days with endoscopy.

Going a little bit lower, the treatment of tracheal injuries, similarly to what happens in esophageal trauma, depends upon the extension of the tissue loss, or, in other terms, upon the number of tracheal rings missing:

• ≤2 tracheal rings missing – primary repair can be attempted;
• >2 tracheal rings missing – insert a tracheostomy tube through the hole and close it as much as possible the laceration, creating an airtight seal over the hole using a sternocleidomastoid m. or pericardial patch.

The suture should be performed using interrupted 4/0 absorbable stitches.

Ok, guys… We think we gave you enough information to digest…

We hope this post will help you manage these rare but fearsome injuries…

By the way, go back to the clinical case… Isn’t it that difficult to answer the questions, is it?

Until next time… Be good, be brave, be an acute care surgeon!!!

References

1. Sperry JL, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg 2013;75:936-40.
2. Shiroff AM, et al. Penetrating neck trauma: a review of management strategies and discussion of the “No Zone” approach. Am Surg 2013;79:23-9.
3. Moore EE, et al. Trauma. 8^th Ed. New York, NY: McGraw-Hill Education; 2018.
4. Boffard KD. Manual of Definitive Surgical Trauma Care. 5^th Ed. Boca Raton, FL: CRC Press; 2019.
5. Demetriades D, et al. Atlas of Surgical Techniques in Trauma. 1^st Ed. Cambridge, UK. Cambridge University Press; 2015.
6. Demetriades D, et al. Cervical pharyngoesophageal and laryngotracheal injuries. World J Surg 2001;25:1044-8.
7. Biffl WL, et al. Western Trauma Association critical decisions in trauma: diagnosis and management of esophageal injuries. J Trauma Acute Care Surg 2015;79:1089-95.

How to Cite This Post

Bellio G, Marrano E. French Revolution Style. Surgical Pizza. Published on April 8, 2023. Accessed on May 27, 2023. Available at [https://surgicalpizza.org/trauma/french-revolution-style/].