![]() ![]() The right neck structures are distended, displaced, and swollen due to edema and extravasation (Image 2). The bullet is lodged in the right lateral mass of C1. She is then taken for CT angiography of the neck and found to have complete occlusion of the right internal carotid artery, with possible transection (Image 1). Prior to tracheotomy in the OR, an attempt at blind nasotracheal intubation is made and is successful. These patients may require emergent thoracotomy for hemorrhage management. Zone 1 injuries (below the cricoid cartilage) may involve the subclavian vessels bleeding here is notoriously difficult to control. If that fails, consider placing a Foley catheter to tamponade the bleeding. Do not blindly attempt to clamp vessels, as this also may cause further injury.ĭirect compression can be attempted to control bleeding of an open neck wound. Avoid probing through the wound, as this may disrupt a clot. On the other hand, if there is violation of the platysma, further evaluation is necessary. If not, then primary repair and ED discharge can be arranged as long as there is no concern for blunt trauma to the adjacent structures in the neck. The first question is whether it violates the platysma muscle. Open wounds in the neck require special attention. 4 How Do I Manage an Open Wound in the Neck? Of these attempts, 3 failed this management, but then were successfully intubated using RSI. In this study, primary management of the airway via fiberoptic intubation by ENT specialists was attempted in 12 patients. Mandavia, et al, reporting on 58 patients with critical airway compromise in neck trauma, found that two-thirds of the airways were managed successfully with standard RSI. If time permits, tracheostomy would be the best approach.ĭespite the multiple serious confounders, the familiarity of the emergency physician with RSI makes it the preferred technique in the majority of penetrating neck traumas (with appropriate scrupulous use of paralytics). If there is a hematoma overlying the cricothyroid membrane, performing a cricothyrotomy is contraindicated. Paralysis should be avoided in these patients, and a cricothyrotomy should be considered, with the appropriate tray and tools at hand. Special caution is warranted for the patient with suspected blunt laryngeal injury, as orotracheal intubation may be impossible. Options include rapid sequence intubation, oral intubation with sedation or local airway anesthesia only, blind nasotracheal intubation, direct fiberoptic intubation, retrograde guidewire intubation, cricothyrotomy, and placement of an endotracheal tube through an open wound in the neck (should one be available). ![]() The ideal approach for securing the airway is controversial. Criteria for Emergent Airway Management in Penetrating Neck Trauma 3 Stridor ![]() The criteria for emergent airway management in penetrating neck trauma are outlined in Table 1. In traumatic neck injuries, an earlier intubation usually means an easier intubation because there is less time for airway distortion, swelling, and patient deterioration. Who Needs Immediate Airway Attention?Ī fundamental principle of airway management is that earlier airways are generally easier airways. 2 Appropriate and timely management of neck injuries is a critical skill for the emergency physician. 1 Mortality, particularly for vascular injuries, approaches 50%. Penetrating neck injuries account for up to 5%-10% of all traumatic injuries. If a neck injury is missed during the initial stages of a polytrauma evaluation, it can result in increased morbidity and mortality. The neck is the location of many vital structures. The case scenario presented here may represent one of the more challenging airways you might ever encounter. Given the extent and nature of her injury, there is concern for impending airway compromise, and it is decided to take the patient to the OR for emergent tracheotomy.įor every ED physician the trauma resuscitation starts with the ABCs: airway, breathing, and circulation. Initial assessment reveals facial swelling and large amounts of blood in the oropharynx, though she is initially stable on a non-rebreather. A 57-year-old female is brought in to the emergency department after sustaining a gunshot wound to the right face. ![]()
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