Penetrating injuries of the neck. Emergency evaluation and management

The physician who is called upon to attend to a penetrating wound to the neck must set priorities in management. (1) Establish a safe airway. (2) Maintain adequate cardiocerebral perfusion. (3) Assess and identify the type and severity of the wound so that proper decisions can be made about further evaluation and/or transfer for immediate surgical intervention. All this can be accomplished in an orderly fashion by applying the principles for selective surgical exploration of neck wounds outlined in this article. A well-reasoned approach can help avoid unnecessary surgery and yields a high likelihood of recovery.     

Penetrating neck injuries: experience with selective exploration

Although many authors have stated that surgical exploration should be mandatory for all neck wounds that penetrate the platysma, recent reports from many centers now claim that selective exploration is both safe and reasonable. A policy of selective exploration based on clinical presentation, anatomic location, and results of diagnostic studies has been followed at The Cooper Green Hospital in Birmingham, Alabama, for the past 13 years. We report a study of penetrating neck wounds in 136 consecutive patients admitted to The Cooper Green Hospital from 1972 to 1984. Seventy-seven patients (57%) had exploration immediately, with one death, while the remaining 59 (43%) were admitted and observed. Of these 59 patients, ten had arch aortography and nine had esophagography, all of which yielded normal results. The remainder of the patients observed had no clinical signs or symptoms to suggest a major injury. There were no deaths or complications related to the neck wounds in the 59 patients observed. Results of 27 explorations (35%) were negative. We conclude that selective exploration of penetrating neck wounds is both safe and reasonable.     

Penetrating injuries of the laryngotracheal area.

Penetrating injuries of the laryngotracheal area require immediate maintenance of an adequate airway and prompt surgical exploration and repair. Two basic principles are illustrated by case reports: repairing major vessels before doing the laryngotracheal repair and using adjacent tissues to repair traumatic defects. We suggest a team approach at operation.     

Penetrating injuries of the larynx

Patients with penetrating laryngeal trauma can present a wide spectrum of signs and symptoms. Severe trauma frequently leads to life-threatening airway compromise, whereas lesser injuries are often overlooked because of the subtlety of physical and roentgenographic findings or the severity of vascular and neurologic injuries. Increased suspicion should accompany the examination of patients who have sustained a penetrating neck injury, and such injuries demand examination by an experienced laryngoscopist. Early surgical repair is mandatory to avoid delayed complications, which can permanently impair airway, speech, and deglutition. In a series of 19 patients presented here, diagnosis was delayed in seven (37%). The most relevant factor determining return to normal voice appeared to be the presence or absence of vocal cord paralysis.     

Penetrating ocular injuries

Penetrating ocular and orbital trauma present the emergency medicine physician with ongoing challenges. A suspicion of their occurrence with understanding and prompt recognition of presenting signs ultimately will give the patient the best possible visual outcome.     

Penetrating cardiac injuries

In the past 6 years 65 patients with penetrating wounds of the heart have been operated upon. The mortality was 13% in 47 patients with stab wounds and 50% in 18 patients with gunshot wounds. Fifty-eight consecutive patients in whom a cardiac wound was suspected were operated upon immediately, with a survival rate of 84.5%. It is proposed that pericardiocentesis should be utilized only for diagnosis and that immediate thoracotomy should be the definitive treatment for penetrating wounds of the heart.     

Penetrating eye injuries in road traffic accidents.

A review of all penetrating eye injuries treated by the Manchester Eye Hospital over four years (1 February 1982-31 January 1986) was undertaken. One hundred and ninety-six penetrating eye injuries were seen, of which 16 (8.2%) were due to road traffic accidents. Eight patients (nine eyes) were seen in the 12 months prior to the introduction of the seat-belt legislation on 1 February 1983. None of these patients was wearing a seat-belt whereas two of the eight patients (10 eyes) seen after the seat-belt legislation were. Both these patients suffered severe visual loss due to intraocular glass from shattered windscreens. Three patients had bilateral penetrating eye injuries, one before and two after the seat-belt legislation. Two of the nine eyes involved prior to the legislation and three of the 10 eyes after the legislation had an eventual visual acuity of 6/12 or better. In the majority of patients, failure to wear seat-belts or defective use is to blame. Flying glass from shattered toughened windscreens is a preventable danger. Nine of the 16 patients were first seen in the general accident and emergency department and, of these, seven did not have visual acuities recorded prior to referral to an ophthalmologist. The importance of measurement of the visual acuity and detection of an afferent pupillary defect is stressed based on these findings.     

Penetrating orbito-cranial and ocular cow-horn injuries

Cow horn eye injuries are not common but are devastating causes of uniocular blindness amongst young active population. Early and appropriate intervention can save the life of the patient depending on the severity of the injury. This uncommon cause of unilateral visual loss can be prevented if slaughtering of cows are done by trained and appropriately equipped personnel.     

Self-inflicted shotgun injuries to the face: a case report.

Shotgun injuries to the face are difficult to care for due to the often massive tissue and bone destruction and the complications that can accompany these injuries. Psychological responses from the family, significant other, and nursing staff in dealing with disfiguring and sometimes fatal injuries are additional challenges that nurses will face.     

Cavernous lymphangioma of the face and neck: prenatal diagnosis by three-dimensional ultrasound.

Cavernous lymphangiomas are characterized by penetration through the subcutaneous areas between the muscular septa and represent rare variants of the more common superficial lymphangioma. Although frequently described in the fetus when involving the posterior aspect of the neck (i.e. cystic hygroma), involvement of the craniofacial region is rare. We describe the prenatal findings in a case of cavernous lymphangioma of the fetal face and neck, which extended caudally to envelop the larynx and the trachea. The anomaly was assessed by two- and three-dimensional (3D) ultrasound. The latter approach was used thoroughly both during counseling with the couple and during consultation with the pediatric surgeon. This case report confirms the usefulness of the 3D approach in the management of rare fetal anomalies. In particular, the possibility of navigating the volume facilitated consultation with the pediatric surgeon and counseling of the parents.     

Head and neck symptoms. Is the problem in the ears, face, neck, or oral cavity?

There is a complex anatomic and physiologic relationship among head and neck structures. Because of this complexity, patients with problems in any of these structures often present with a wide range of symptoms and physical findings. The authors describe many head and neck conditions that are encountered in a busy practice and emphasize selection of diagnostic studies and appropriate referral for treatment.