HPI: 41yo male self-inflicted stab wounds to neck and chest

PE: VS are unremarkable

GENERAL: speaking in 2 word sentences, GCS 15

NECK: Two laceration to the left anterior neck, with slow oozing and bubbling from the medial laceration, +palpable crepitus throughout the neck　

CHEST: crepitus over neck and upper chest, with small superficial laceration to the right upper chest

DDx:

• Concern for injury to trachea +/- esophagus, vascular, or neuro structures
• PTX vs hydrothorax vs pneumomediastinum

Initial management:

• ABCs!!
• Airway: anticipate difficult airway; use VL or fiberoptic/ flexible intubating bronchoscope for intubation and anticipate possible cricothyrotomy
• Breathing: up to 20% have hemo- or pneumothorax
• Circulation: hold pressure on bleeding wounds (but not both carotids simultaneously) In patients with penetrating neck trauma

Diagnostics:

• Physical exam is >95% sensitive for detecting clinically significant vascular and aerodigestive injuries
• CXR: note subcutaneous emphysema, +pneumomediastinum, +ETT in place, note two washers marking neck wounds

Management:

• Assess airway and look for signs for aerodigestive injury
• OR for neck exploration if: shock, expanding hematoma, active bleeding, subcutaneous emphysema, dysphagia, hoarseness, stridor, or obvious tracheal or esophageal injuries
• "Hard signs" of need for OR: include air bubbling from the wound, expanding hematoma, hematemesis, shock, diminished radial pulse, +/- neuro deficits
• This patient was intubated using VL and there was blood seen just below cords prior to passing ETT
• Patient was taken level 0 to the OR for neck exploration　

Take home points:

• Zone I → CTA chest
• Zone II → Violation of platysma → send to OR; if not, OBSERVE. Wounds that do not penetrate the platysma are not life threatening
• Zone III → CT neck with contrast +/- angiography. Leave impaled objects as they may be providing tamponade
• DON’T FORGET YOUR ABCs!

References:

Tisherman SA, Bokhari F, Collier B et al.: Clinical practice guideline: penetrating zone II neck trauma. J Trauma 64: 1392, 2008.

Stover EC. Stover E.C. Stover, Emily C.Maxillofacial & Neck Trauma. In: Stone C, Humphries RL. Stone C, Humphries R.L. Eds. C. Keith Stone, and Roger L. Humphries.eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e New York, NY: McGraw-Hill; . http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2172&se.... Accessed September 07, 2019.

Bean AS. Bean A.S. Bean, Ashley S.Trauma to the Neck. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. Eds. Judith E. Tintinalli, et al.eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&se.... Accessed September 07, 2019.