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This
chapter
aims to
discuss
the
manage
ment of
soft
tissue
neck
injuries.
It is
specifical
ly
directed
away
from the
manage
ment of
the
cervical
spine
and
spinal
injury in
trauma
patients.
We
mainly
refer to
penetrati
ng neck
injuries,
however
the
assessm
ent and
manage
ment of
any neck
soft
tissue
injury
should
follow a
common
pathway
in our
opinion.
Specific
consider
ation of
skin
involvem
ent in
these
injuries is
also left
to other
texts.
Soft
tissue
injuries
in the
neck are
difficult
to
assess
and
manage.
This
compact,
important
anatomic
al area
contains
a dense
concentr
ation of
vital
vascular,
aero-
digestive
and
nervous
system
structure
s; many
of which
are not
accessibl
e to
physical
examinat
ion and
surgical
exposure
is a
challeng
e. There
has been
a shift
away
from
early
aggressi
ve
operative
manage
ment to a
more
selective
and
conserva
tive
approach
,
however
controver
sy still
exists.
(Demetri
ades et
al. 1996)
A
thorough
review of
current
literature
has been
made to
give the
best
available
evidence
base; the
referenc
es are
included
at the
end of
the
chapter.
• Difficult to manage
History
• 2nd world war, 851 cases of neck injury were reported with a 7%
mortality, in Vietnam this rose to 15% (Thal 1988)
Neck anatomy
The anatomy of the neck is unique as it contains many vital structures
representing the most important body systems. Traditionally an anatomical
scheme to look at the neck uses triangles, each triangle containing different
vital structures and coated by muscle, fascia and skin. Classically the neck is
divided into anterior and posterior triangles by the sternocleidomastoid
muscle.
The anatomical structures in the neck structures are invested by two fascial
layers:
1. The superficial fascia lies just beneath the skin and encompasses
the body of platysma (a thin superficial muscle that originates over
the upper part of the thorax and passes over the clavicles across the
neck and blends with the superficial musculo-aponeurotic system
(SMAS) of the face).
• Respiratory
• Digestive
• Endocrine
• Central nervous system
Such tight fascial compartmentalisation of the neck structures limits external
bleeding from vascular structures (Fig. 1). This beneficial effect is countered
by the dangers of bleeding within these closed spaces, which can
compromise the airway.
Figure 1: Cross sectional view of cervical fascial planes (from Gray SW,
Skandalis JE, McClusky DA: Atlas of Surgical Anatomy. Baltimore, Williams &
Wilkins, 1985, p15, with permission).
Figure 2: Anatomic zones of the neck (from Feliciano, Moore & Mattox:
Trauma 3rd edition. Appleton & Lange 1996, p330, with permission).
Mechanisms of injury
Classification of neck injury can be accomplished in different ways. The
anatomical site of injury and the related structures are vital, however the
history, mechanism and pattern of injury also give us important information
and clinicians should get as much history as possible from the pre-hospital
carers / ambulance personnel.
Epidemiology
• The most common site of injury is the anterior triangle of the neck
Initial management
An “ABC” approach to all trauma patients has now become standard thanks
to the teaching of Advanced Trauma Life Support (ATLS). As part of this
teaching, the assessment and immediate management of life threatening
problems go hand in hand in a stepwise progression. The presence of a
bleeding neck wound shouldn’t detract from an airway injury, respiratory
distress, stridor and altered level of consciousness mandating emergency
airway management. (Walls, Wolfe, & Rosen 1993) The importance of this
process cannot be emphasised too much; approximately 10% of patients with
penetrating neck injuries present with airway compromise. (Pate 1989) 25-
40% have a vascular injury (10% carotid artery), 10% have a respiratory tract
injury.
Expeditious pre-hospital transfer without intervention in the urban
environment, gives the patient with life threatening soft tissue neck injury the
best chance of survival. Airway and respiratory care are paramount and early
endotracheal intubation should be considered if patients present with
symptoms of respiratory obstruction:
• Restlessness
• Stridor
• Air hunger
• Hoarseness
• Tracheal tug
• Retraction of supraclavicular, intercostals or epigastric areas
• Cyanosis
• Inability to swallow and drooling
There are other schemes based on findings in zones of the neck, (Klyachkin
et al. 1997;Velmahos et al. 1994). The basic aim is to have a fast and
effective method of assessment, so that injuries are not missed and over
treatment avoided.
A chart to aid the examination and recording of this type of injury has been
proposed by Demetriades et al (Figure 4). Some authors feel that
examination alone is sufficient in the assessment of Zone 2 neck injuries
whilst others feel that it is reliable in all Zones (Demetriades et al.
1995;Demetriades, Theodorou, Cornwell, Berne, Asensio, Belzberg,
Velmahos, Weaver, & Yellin 1997;Jarvik et al. 1995;Kendall, Anglin, &
Demetriades 1998;Velmahos, Souter, Degiannis, Mokoena, & Saadia 1994).
Emergency Treatment
• ABC approach
• Operate or investigate
Adve
rtise
Curr
ently
onlin
e
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