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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Management Of Gunshot Wounds To The Neck

The high concentration of critical anatomy located in the neck makes penetrating neck injuries potentially life-threatening. Penetrating neck injury caused by even a single bullet has the potential to cause multiple devastating injuries.

A rapid and thorough physical examination is important in penetrating neck injury, as it may provide important clues to the severity of injury. Some authors suggest that physical examination is a reliable indicator of injury in penetrating neck wounds, and certain asymptomatic patients may be evaluated with observation alone.60,61 In one study, patients with penetrating neck injuries whose physical examination did not show signs indicative of surgical injuries were also evaluated with CT scans. The authors concluded that CT scan added little information in patients determined by physical examination to be low-risk.62 The decision on whether to proceed with imaging versus purely observational management must be made in consultation with the surgeon. Typical practice patterns in the United States include liberal use of CT imaging in penetrating neck trauma, and the risk-to-benefit ratio of CT scan to identify serious underlying neck injury is low. If there is any question of a possible serious neck injury, a CT with angiography should be obtained to evaluate for vascular or aerodigestive tract injuries.63 All patients with penetrating neck injury violating the platysma should be observed for a minimum of 24 hours.60

Airway Management In Neck Injuries

Neck wounds have the potential to make intubation extremely difficult by obscuring visualization due to bleeding and/or altered anatomy. Rapid sequence intubation is a commonly performed procedure in the ED; however, traditional teaching cautions against using paralytics in the patient with penetrating neck trauma. It is theorized that the addition of a paralytic may turn a spontaneously breathing patient into a patient that can neither be intubated nor ventilated, and therefore, a crash airway.

There are very few studies evaluating the management of the airway in penetrating neck trauma. More-recent literature indicates that RSI is likely a safe and effective way of managing the airway in penetrating neck injuries. One small study of 58 patients with penetrating neck injury requiring emergency airway control showed a 100% success rate in the 39 patients who were intubated using RSI alone. This same study noted 3 unsuccessful fiberoptic intubations that were then successfully intubated using RSI. No patients in this study required a surgical airway.64 In 2004, another retrospective review of patient charts showed successful intubation with RSI in the ED as well as a 90% success rate with prehospital blind nasotracheal intubation (BNTI). This study calls into question the traditional teaching that BNTI is contraindicated in patients with neck injury for fear of worsening an airway injury.65

Although current literature indicates that RSI is a safe and effective method of managing the airway in patients with penetrating neck injury,64-66 these situations are highly variable and have the potential to be difficult intubations. A clearly defined backup strategy must be in place, including a variety of airway devices. In addition, preparation for an emergent surgical airway must be made, if possible, prior to inducing the patient for RSI (double setup). If the patient appears stable in the ED without signs of acute airway compromise or other indications for emergent intubations, it is prudent to transport the patient to the operating room for definitive airway management.

Extreme caution should be exercised in patients with penetrating neck injuries likely to have caused partial or total tracheal transection, as orotracheal or nasotracheal intubation attempts could lead to separation and retraction of the distal tracheal segment. If control of the distal segment can be maintained with a tracheal hook or other device, then a patient with an open tracheal injury may be directly intubated with an endotracheal or tracheostomy tube.

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