Penetrating neck injuries & blunt cerebrovascular injuries

South East Scotland Major Trauma Guidelines
NHS Lothian

Objectives

BCVIs will not be seen on initial CT scans unless specifically requested. Up to 20% will be
missed with stroke being the most devastating consequence

Anatomical zones of the neck

Zone 1: Clavicle and sternal notch to cricoid cartilage
Zone II: Cricoid cartilage to the angle of the mandible
Zone III: Angle of mandible to base of skull.

Management principles

  • If the platysma is not breached, a serious injury is effectively excluded
  • If this distinction cannot be made then further investigation is required
  • Ensure early airway assessment and consider a definitive airway early where appropriate 

Consider a definitive airway early in the penetrating neck injuries 

Access for hard and soft signs

Hard Signs Soft Signs

Active haemorrhage

Pulsatile / expanding haematoma
Bruit/thrill
Haemodynamic instability
Unilateral upper limb pulse deficit
Massive haemoptysis / haematemesis
Air bubbling in the wound
Airway compromise
Cerebral Ischemia

Major Haemorrhage
1) Apply direct pressure
2) Consider haemostatic dressings
3) Foley catheter

 Non pulsatile / non expanding haematoma Venous oozing
Dysphagia
Dysphonia
Subcutaneous emphysema

Imaging vs. theatre

  • Unstable patients with hard signs require emergency surgery
  • Perform immediate CTA Neck in patients with hard signs not requiring emergency surgery
  • Perform immediate CTA Neck in patients with soft signs

Other injuries to consider

If there is concern for aerodigestive injury despite normal / equivocal CTA:

  • Consider barium swallow in conjunction with laryngoscopy / esophagoscopy
  • Consider ENT and cardiothoracic involvement as required

Some Zone 1 injuries will require a thoracotomy for proximal control.

Extended Denver criteria

Signs/Symptoms Risk Factors (High energy mechanism
AND)
• Arterial haemorrhage from neck, nose or mouth
• Cervical Bruit (<50yr old)
• Expanding cervical haematoma		 • Le Fort II or III facial fracture
• Mandible fracture
• Complex skull/BOS/occipital condyle fracture
• Focal Neurology (TIA, hemiparesis,
posterior symptoms, Horners)		 • Severe TBI with GCS <6
• Unstable C-Spine fracture
• Neurological deficit inconsistent with
CT head		 • Near hanging with anoxic brain injury
• Stroke on CT/MRI • Clothesline/seat belt injury with significant swelling/pain or reduced GCS
• TBI with thoracic injuries
• Thoracic vascular injuries
• Scalp degloving
• Upper rib fractures
• Blunt cardiac rupture

Grades of injury

  • Grade I (intimal injury <25% narrowing)
  • Grade II (dissection or intramural haematoma >25%)
  • Grade III (pseudoaneurysm)
  • Grade IV (occlusion)
  • Grade V (transection with extravasation) 

Management

  • Surgery is indicated for grade II, III, IV & V injuries that are surgically accessible
  • Endovascular treatment for grade V injuries that are not surgically accessible
  • Treat grade I injuries and grade II, III, IV and V injuries not undergoing surgical intervention with aspirin (or heparin) and repeat CTA in 7-10 days
  • If repeat CTA shows a healed injury stop treatment otherwise continue treatment fo 3-6 months and re-image

Editorial Information

Last reviewed: 01/09/2021

Next review date: 01/09/2024

Version: 1.0