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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.

Evaluation Of Neck Injuries

Penetrating neck injuries are traditionally classified into 3 zones, which are described in Table 7. The zones provide a framework for discussing injuries with consulting services as well as indicating potentially injured structures and ease of surgical exploration. Zones 1 and 3 are difficult areas to expose surgically, and injuries to these areas are evaluated by additional imaging in the stable patient. Zone 2 is fairly easy to expose surgically, and penetrating injuries in this zone have traditionally been treated with mandatory surgical exploration. Nonetheless, advances in imaging technology and large numbers of negative surgical explorations have called this dogma into question.

As with all trauma patients, the unstable patient with injury to any of the zones of the neck should be taken immediately to the operating room. However, the stable patient may undergo a series of imaging studies to better evaluate the extent of injury. Recent practice guidelines from EAST offer a Level I recommendation that selective operative management of zone 2 neck injuries is recommended to minimize unnecessary operations.67 Because it can be difficult to determine the zone(s) of injury based on the external gunshot wound, diagnostic imaging or operative management is required to visualize the zones that are injured.

Imaging options for arterial injury in the neck include angiography, CT angiography (CTA) and duplex ultrasonography. Angiography is useful because it can be both diagnostic and therapeutic; however, it is also a time- and labor-intensive test. Recent studies have shown that CTA is a reasonable alternative to angiography for imaging the vasculature of the neck.68,69 In addition, CTA can provide information regarding the trajectory of the projectile as well as visualizing other injuries. A CT scan showing a trajectory remote from vital structures may obviate the need for further imaging or unnecessary surgery in a stable patient.70 The use of CTA has been shown to significantly reduce the number of negative neck explorations with no increase in mortality.71

Duplex ultrasound has also been proposed as an imaging modality for vascular injury in penetrating neck trauma. Corr et al performed a prospective study in 1999 on 25 patients with penetrating neck injury, showing 100% sensitivity of duplex ultrasound as compared to angiography.72 Demetriades et al found similar results using ultrasound in 99 patients who also underwent angiography. They found a sensitivity of 91.7% and specificity of 100%. When only lesions requiring treatment were considered, both the sensitivity and specificity were 100%.73 In recent practice guidelines, EAST allows for use of CTA or duplex ultrasound instead of arteriography to rule out arterial injury (Level II recommendation).67

Evaluation of the aerodigestive tract is accomplished by contrast studies or by direct visualization. Computed tomography evaluation of the trachea has been shown to reliably diagnose injury.74 Esophageal and pharyngeal injuries, however, can be difficult to evaluate, and there are often no physical examination findings on presentation. Delay of more than 24 hours in the diagnosis of esophageal injuries can lead to increased morbidity and mortality.75 Although CT scanning cannot reliably evaluate for esophageal trauma, some studies suggest that a CT scan showing a bullet trajectory remote to the esophagus can reliably risk stratify patients to a very-low-risk category suitable for 24-hour observation.70 In most patients sustaining gunshot wounds to the neck, however, it is likely that an esophagogram should be performed. Esophagography has a sensitivity approaching 100%.76 A strategy of esophagography followed by esophagoscopy was recommended by Weigelt et al for the identification and evaluation of esophageal injury.77 The clinical practice guidelines from EAST recommend either contrast esophagography or esophagoscopy to rule out an esophageal perforation that requires surgical repair.67

 
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Last Modified: 07/19/2018
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