Throat Laceration In A College Hockey Player - Page #4
 

Working Diagnosis:
Penetrating neck injury with no major neurovascular, muscular, or tracheal involvement

Treatment:
Laceration repair

Outcome:
The patient was not found to have any significant neurovascular, muscular, or structural injury. His laceration was repaired with a 3-layer closure and he was discharged home with outpatient sports medicine and surgical clinic follow up.

On follow up at Sports medicine clinic 6 days later, the patient was noted to have a well healing wound that was clean/dry/intact. Upon follow up in the surgical clinic 9 days after the event, stitches were removed and the patient was cleared to return to all activities without restrictions.

Author's Comments:
Penetrating neck injury is considered any injury that penetrates or violates the platysma. Anterior neck injuries are often divided into 3 different zones. Anatomic landmarks traveling upward from the base of the neck are described as: Zone 1 clavicle to cricoid, Zone 2 cricoid to angle of mandible, Zone 3 angle of mandible to base of skull. Injuries in zone 1 have the highest mortality due to risk of involving intrathoracic structures.

The patient with a penetrating neck injury should be transported immediately to the nearest trauma center. ABCs should be managed as with any trauma. Prehospital and initial hospital management are focused on active bleeding and airway compromise. Any impaled objects should remain in place. Positive pressure ventilation such as bag mask ventilation can potentially force air into soft tissue planes subsequently leading to anatomical distortion. Spinous injury from anterior neck trauma is uncommon and immobilization may not be necessary depending on the circumstance. Patients in obvious distress should undergo immediate stabilization of the airway. Findings suggesting significant penetrating neck trauma include significant bleeding/hematoma, subcutaneous emphysema, bruit or thrill, associated neurological deficits, distorted neck anatomy, stridor/respiratory distress, pain or trouble with swallowing, changes in phonation, hemoptysis, signs of shock. In such cases RSI can be used to establish airway when necessary, preparation should be undergone for backup airway methods including surgical airway or other orotracheal methods.

Editor's Comments:
All penetrating neck injuries should include an emergency surgical consultation/trauma assessment. While there is no clear consensus, general recommendations for evaluations of unstable patients with penetrating neck injuries are immediate surgical exploration. Patients who are stable are recommended to undergo CT angiography imaging of the neck to evaluate for further injuries. Intact pulses do not rule out vascular injury. Pharyngoesophageal injuries are less common however are associated with high morbidity/mortality. Subtle signs including dysphasia, blood in the saliva can be indicative of such an injury. High suspicion to be maintained regarding occult injuries including esophageal injuries which can be missed by CT imaging, these patients often are recommended to undergo additional esophagram imaging. Penetrating neck injury less commonly involves the central nervous system or peripheral nervous system, however any concern for nervous system injury should be further explored.

References:
Recognizing and Managing Traumatic Neck Injuries. Eric Ernest-R.J. Frascone-Aaron Burnett - https://www.jems.com/2014/04/02/recognizing-and-managing-traumatic-neck/

Penetrating Neck Injuries: a Guide To Evaluation and Management. J Nowicki-B Stew-E Ooi - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849205/

Penetrating and Blunt Trauma To the Neck: Clinical Presentation, Assessment and Emergency Management. P Verdonck-J de Schoutheete-K Monsieurs-C Van Laer-V Vander Poorten-O Vanderveken - https://www.ncbi.nlm.nih.gov/pubmed/29558578

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