2.0 ANCC CONTACT HOURS
Getting ahead of
penetrating neck injuries MR. G, AGE 29, is transported to the ED’s trauma resuscitation room by ambulance. The paramedics report that during an altercation at a party, the patient had been stabbed in the right side of the neck with an unknown object. They report finding a significant amount of blood at the scene, as well as many empty beer and liquor bottles. They also report that the patient has no significant medical or surgical history, takes no medications, and has no known drug allergies. 36 l Nursing2014 l October
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
OJO _ IMAGES /iSTOCK
By Mark McGraw, BSN, RN, CEN, CCRN, CTRN
www.Nursing2014.com
October l Nursing2014 l 37
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The paramedics have the patient fully immobilized with a long board, straps, and cervical collar. Several layers of saturated dressings are in place over his wound, and a paramedic is maintaining manual pressure to control bleeding. One liter of normal saline solution is infusing via a 16-gauge peripheral venous access device inserted in the patient’s right upper extremity. Paramedics reported that his respirations had become much more labored and his Spo2 levels had been slowly falling despite supplemental oxygen. Breath sounds became more diminished on the right before they gradually disappeared. On physical assessment, Mr. G is awake, alert, and oriented, and his speech is clear and appropriate. He’s diaphoretic, and his global pallor indicates significant blood loss as the result of his injury. His skin is moist and his right upper extremity is cool to the touch. As he receives less and less perfusion to that extremity, he begins to complain of parasthesias and numbness. He has no palpable right upper extremity
pulses; because the injury severed the subclavian artery, he wouldn’t have any pulses distal to the injury unless he had collateral blood flow to the region. His vital signs are tympanic temperature, 96.4° F (35.8° C); heart rate, 144 and regular; respirations, 30 and shallow; Spo2, 94% on a 100% nonrebreather face mask; and BP, 88/68. Based on this patient’s clinical presentation and history of injury, his nurse recognizes the critical nature of a penetrating neck injury. Determining the precise location and severity of the injury will help guide treatment decisions and prevent secondary injury. This article outlines the dangers of a penetrating neck injury and the immediate assessment and care patients need. Critical pathways By definition, a penetrating neck injury diagnosis means that the superficial fascia containing the platysma muscle has been penetrated.1 This muscle originates in the upper chest, extends superiorly over the clavicles, and covers the anterolateral
Close up on the platysma
Platysma
38 l Nursing2014 l October
neck; finally, it’s attached to the lower facial muscles.2 (See Close up on the platysma.) Penetrating neck injuries are a challenging aspect of trauma care because of the close proximity of many vital structures confined in a relatively small area.3,4 As a result, the patient must be assessed for possible laryngotracheal injuries, pharyngoesophageal injuries, nervous system injuries, and vascular injuries. (See Anatomy of critical pathways.) Accounting for 5% to 10% of all trauma cases, penetrating neck injury has a mortality around 3% to 6%. For injuries involving the larger vasculature, however, mortality approaches 50% according to some studies.1,3 In 1979, Roon and Christensen separated the neck into three distinct zones based on anatomical landmarks.5 (See Zooming in on the neck’s zones.) • Zone I, which spans the space between the clavicles and the cricoid cartilage, contains the common carotid, vertebral, and subclavian arteries.1,5 The apices of the lungs extend into this region, along with the trachea, esophagus, thoracic duct, and nerves comprising the brachial plexus.1,3 The aortic arch is in close proximity to this region. • Zone II is anatomically designated between the cricoid cartilage and the angle of the mandible.1,3,5 It contains the larynx, pharynx, base of the tongue, internal and external carotid arteries, jugular veins, spinal cord, thyroid gland, and the cranial nerves (CN) lower in the brainstem, CN X, XI, and XII. • Zone III, the space between the angle of the mandible and the base of the skull, contains the same neck structures as zone II, but some are slightly more superficial as they ascend. Just because the patient experiences an injury to zone II doesn’t mean the wound can’t track down www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anatomy of critical pathways sternocleidomastoid posterior belly of digastric superficial temporal artery maxillary artery external carotid artery posterior auricular artery
internal jugular vein occipital artery hypoglossal nerve
facial artery lingual artery stylohyoid
descending branch of hypoglossal nerve internal carotid artery superior laryngeal nerve deep cervical lymph nodes descending cervical nerve
anterior belly of digastric mylohyoid nerve to thyrohyoid sternohyoid internal laryngeal nerve superior thyroid artery
thyrohyoid ansa cervicalis
spinal part of accessory nerve
external laryngeal nerve thyroid cartilage
superior thyroid vein
cricoid cartilage
common carotid artery
superior belly of omohyoid isthmus of thyroid gland
anterior jugular vein external jugular vein sternothyroid From Snell RS. Clinical Anatomy. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2003.
into zone I and involve high thoracic structures or track up and involve zone III structures. To avoid classifying the patient as not emergent or not a surgical emergency based on the location of the injury, some authors suggest classifying all patients with a neck injury as potential surgical emergencies. Some recommend using a “no zone” algorithm or dividing the neck into triangles, being aware that the most vital structures are located in the anterior www.Nursing2014.com
triangle.1 The anterior triangle is bordered anteriorly by the midline, posteriorly by the sternocleidomastoid muscle, and superiorly by the lower edge of the mandible.2 Clinical decisions Any patient presenting for treatment after a traumatic injury such as a penetrating injury to the neck should be evaluated according to guidelines established by the American College of Surgeons, Society of
Trauma Nurses, and the Emergency Nurses Association. These are the Advanced Trauma Life Support, Advanced Trauma Care for Nurses, and Trauma Nursing Core Course guidelines, respectively.4,6,7 The general recommendations are outlined here. Nurses should pay close attention to the airway, assessing for signs and symptoms that could indicate an airway injury, including subcutaneous emphysema, wound bubbling, hoarseness, or stridor. These could October l Nursing2014 l 39
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
indicate direct injury to the upper airway or to the nerves innervating the glottis. Because these signs and symptoms are considered definitive signs of airway injury, immediate endotracheal intubation is indicated to secure the airway. If the injury impairs the integrity of the larynx or trachea, an emergent cricothyroidotomy or tracheostomy could be indicated, depending on the patient’s clinical status.8 Because the patient must be able to cough to clear secretions and blood that have moved into the airway, the procedure is typically done with minimal sedation, making it potentially difficult for the healthcare team.8 Any signs indicating a vascular injury warrant immediate airway stabilization and transfer to the OR for surgical exploration and repair. These include: • obvious hemorrhage • pulsatile bleeding • evidence of an expanding hematoma • a bruit or thrill over the carotid arteries • asymmetrical arterial pulses.
However, it’s important to remember that the presence of adequate pulses doesn’t rule out the possibility of a vascular injury.1 Because zone I injuries can involve the mediastinum and vascular injuries can result in significant hemorrhage and be difficult to control, critical resources include a cardiothoracic surgeon and perfusionist. They should be made aware of the patient and the possibility of their involvement in the patient’s care. Due to the close proximity of the aortic arch and innominate vessels, cardiopulmonary bypass may be needed to repair the injury.9 These wounds, unlike many others, shouldn’t be explored within the trauma bay; the OR is the appropriate location for surgical exploration and instrumentation because of its many resources.4 Immediate interventions After the initial trauma assessment has been performed, the nurse should insert another large-bore peripheral venous access device in the contralateral upper extremity
Zooming in on the neck’s zones
40 l Nursing2014 l October
and remove the one in the pulseless extremity to avoid further injury.1 Specimens that should be obtained and sent to the lab include a complete blood cell count, basic metabolic panel, coagulation panel, urine drug screen, and a type and crossmatch. Because the neck is a highly vascular region, a penetrating neck injury can quickly cause significant blood loss. Having typed and crossmatched blood on hand will ensure the patient has the most effective oxygen transport system available if needed to perfuse vital organs. A previous standard, based on older wartime experiences, suggested that a patient whose platysma muscle had been penetrated should immediately have surgical exploration with laryngoscopy and esophagoscopy.9 Today, the standard of care has shifted from immediate surgical exploration for all patients to what’s known as the Mansour Algorithm for penetrating neck injuries.10 Several other care pathways take into consideration the extent and location of the injury. Stable patients with zone I or III injuries require angiography to assess the integrity of blood vessels and other structures in the neck.9 Computed tomography with angiography may be needed to help identify the location of the injured vessel because obtaining a comprehensive clinical assessment is difficult. For vascular injuries in zone I, achieving proximal control of the vessel may be difficult because, as the injury occurs, vasospasm and vasoconstriction impair the surgeon’s ability to see and clamp injured vessels. Most injuries in zone II requiring surgery are immediately obvious to the surgeon. Stable patients with zone II injuries that don’t require surgery are typically managed by serial assessments and observation.9,11 www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
To avoid neurologic complications, most vascular injuries should be surgically repaired under anesthesia in the OR as soon as possible. The exceptions to this rule are the vertebral artery and the major venous vessels, which can be safely ligated in the OR without risking neurologic deficits.9 To temporarily stabilize a hemorrhaging wound in a patient waiting for the OR, the surgeon may insert a urinary drainage catheter through the wound tract and inflate the balloon to tamponade the bleeding until the patient can reach the OR for definitive closure.12 Ongoing assessment and intervention The literature presents some conflicting recommendations about whether or not patients with penetrating neck injuries need a cervical spinal collar. The Eastern Association for the Surgery of Trauma’s guideline reports cervical spine immobilization is needed only when a neurologic deficit is present or a proper physical exam can’t be performed due to the effects of mindaltering substances such as alcohol, change in mental status, or unconsciousness.1,3,13 The nurse must exercise extreme vigilance with these patients, and when in doubt, err on the side of caution and not remove the cervical collar without consulting with the trauma team. Because many physiologic centers affecting the cardiovascular system are located in close proximity to the carotid arteries, the nurse can anticipate that an intra-arterial catheter may be inserted to allow direct measurement of the patient’s BP. The care providers must maintain a high index of suspicion for even minor neck wounds because of the potential for rapid deterioration and fatal outcomes. Patients who don’t require immediate surgical intervention should be admitted into the ICU for close observation. www.Nursing2014.com
Any signs indicating a vascular injury warrant immediate airway stabilization and transfer to the OR. Any patient with a suspected venous injury should be positioned with his or her head as low as possible, and gauze impregnated with petroleum jelly should be applied over the wound to help decrease the risk of a venous air embolism.1 Patients with a penetrating neck injury require frequent assessments of their airway not only for patency but also for the airway’s neurovascular status. The nurse can anticipate performing frequent assessments of the patient’s ability to handle secretions as well as to phonate. A change in pitch, quality, or tone of voice could indicate a nerve injury or palsy caused by compression due to an expanding hematoma. If any changes in physical assessment occur, the surgeon should be notified immediately. Assessing bilateral breath sounds and the work of breathing can help to
identify a developing pneumothorax or damage to the phrenic nerve that’s causing unilateral diaphragmatic paralysis. Nurses can assess the cardiovascular system by ensuring perfusion is adequate distal to the injury. The carotid arteries must be auscultated for bruits and palpated for thrills as a means of continuous assessment and monitoring. Assessing mentation, pupillary light reflexes, and cranial nerve function provides valuable information about the integrity of the vessels supplying and draining the cranium. Injury or compression of an expanding hematoma to the baroreceptors or carotid sinuses could have a profound impact on vasomotor tone and may require inotrope or vasopressor support until that injury can be repaired. Getting closure Mr. G is found to have a stab wound to zone I of the right side of the neck with a probable downward angle on the wound. Suspecting a pneumothorax, the nurse preps the patient for chest tube insertion. Upon insertion of the chest tube, 400 mL of bright red blood drains into the collection chamber. Almost immediately the heart rate begins to normalize, Spo2 levels begin to climb, and BP improves slightly. Because of the persistent absence of palpable pulses and a capillary refill time of more than 5 seconds in the right upper extremity, Mr. G is transported to the angiography suite, where a subclavian artery dissection is discovered. Because percutaneous transcatheter embolization couldn’t be performed due to the extent of his injuries, he’s transferred to the OR for definitive repair. The wound is irrigated and closed without further issues. The patient is transported to the postanesthesia care unit before he’s admitted to the step-down unit for monitoring. October l Nursing2014 l 41
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Mr. G makes a full recovery without complications. His chest tube is removed on post-op day 3 and he’s discharged the following morning. Because of the healthcare team’s knowledge about penetrating neck injuries and the structures associated with specific neck zones and their ability to perform an accurate assessment, this patient’s injuries were rapidly identified and corrected. He was subsequently discharged without complications or permanent injury. ■ REFERENCES 1. Newton K. Penetrating neck injuries. UpToDate. 2013. http://www.uptodate.com 2. Newton K. Initial evaluation and management of penetrating neck injuries: initial evaluation and
>
management. UpToDate. 2014. http://www. uptodate.com. 3. Alterman DM, Daley BJ, Selivanov V. Penetrating neck trauma. Medscape. 2012. http://emedicine. medscape.com/article/433306-overview. 4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual. 8th ed. Chicago, IL: American College of Surgeons; 2008. 5. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma. 1979;19(6): 391-397. 6. Society of Trauma Nurses. Advanced Trauma Care for Nurses. Lexington, KY: Society of Trauma Nurses; 2008. 7. Emergency Nurses Association. Trauma Nursing Core Course. 6th ed. Des Plaines, IL: Emergency Nurses Association; 2007. 8. Preston T, Fedok FG. Blunt and penetrating trauma to the larynx and upper airway. Oper Tech Otolaryngol. 2007;18(2):140-143. 9. LeBoeuf HJ, Quinn FB. Penetrating neck trauma. In: Quinn FB, ed. Dr. Quinn’s Online Textbook of Otolaryngology: Grand Rounds Archive; 1999. http:// www.utmb.edu/otoref/Grnds/Pen-necktrauma-9901/Pen-neck-trauma-9901m.pdf.
10. Mansour MA, Moore EE, Moore FA, Whitehill TA. Validating the selective management of penetrating neck wounds. Am J Surg. 1991;162 (6):517-520; discussion 520-521. 11. Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J. 2008;25(11):711-715. 12. Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg. 2012;99 (suppl 1):149-154. 13. Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008;64(5):1392-1405. http:// www.east.org/resources/treatment-guidelines/ penetrating-zone-ii-neck-trauma. Mark McGraw was formerly a staff nurse at Christiana Care Health System in Newark, Del. Currently, he’s a full-time student in the MSN program at Villanova University in Villanova, Pa., with a concentration in nurse anesthesia. The author and planners have disclosed no potential conflicts of interest, financial or otherwise. DOI-10.1097/01.NURSE.0000453724.85369.e3
Getting ahead of
penetrating neck injuries MR. G, AGE 29, is transported to the ED’s trauma resuscitation room by ambulance. The paramedics report that during an altercation at a party, the patient had been stabbed in the right side of the neck with an unknown object. They report finding a significant amount of blood at the scene, as well as many empty beer and liquor bottles. They also report that the patient has no significant medical or surgical history, takes no medications, and has no known drug allergies. 36 l Nursing2014 l October
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
OJO _ IMAGES /iSTOCK
By Mark McGraw, BSN, RN, CEN, CCRN, CTRN
www.Nursing2014.com
October l Nursing2014 l 37
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The paramedics have the patient fully immobilized with a long board, straps, and cervical collar. Several layers of saturated dressings are in place over his wound, and a paramedic is maintaining manual pressure to control bleeding. One liter of normal saline solution is infusing via a 16-gauge peripheral venous access device inserted in the patient’s right upper extremity. Paramedics reported that his respirations had become much more labored and his Spo2 levels had been slowly falling despite supplemental oxygen. Breath sounds became more diminished on the right before they gradually disappeared. On physical assessment, Mr. G is awake, alert, and oriented, and his speech is clear and appropriate. He’s diaphoretic, and his global pallor indicates significant blood loss as the result of his injury. His skin is moist and his right upper extremity is cool to the touch. As he receives less and less perfusion to that extremity, he begins to complain of parasthesias and numbness. He has no palpable right upper extremity
pulses; because the injury severed the subclavian artery, he wouldn’t have any pulses distal to the injury unless he had collateral blood flow to the region. His vital signs are tympanic temperature, 96.4° F (35.8° C); heart rate, 144 and regular; respirations, 30 and shallow; Spo2, 94% on a 100% nonrebreather face mask; and BP, 88/68. Based on this patient’s clinical presentation and history of injury, his nurse recognizes the critical nature of a penetrating neck injury. Determining the precise location and severity of the injury will help guide treatment decisions and prevent secondary injury. This article outlines the dangers of a penetrating neck injury and the immediate assessment and care patients need. Critical pathways By definition, a penetrating neck injury diagnosis means that the superficial fascia containing the platysma muscle has been penetrated.1 This muscle originates in the upper chest, extends superiorly over the clavicles, and covers the anterolateral
Close up on the platysma
Platysma
38 l Nursing2014 l October
neck; finally, it’s attached to the lower facial muscles.2 (See Close up on the platysma.) Penetrating neck injuries are a challenging aspect of trauma care because of the close proximity of many vital structures confined in a relatively small area.3,4 As a result, the patient must be assessed for possible laryngotracheal injuries, pharyngoesophageal injuries, nervous system injuries, and vascular injuries. (See Anatomy of critical pathways.) Accounting for 5% to 10% of all trauma cases, penetrating neck injury has a mortality around 3% to 6%. For injuries involving the larger vasculature, however, mortality approaches 50% according to some studies.1,3 In 1979, Roon and Christensen separated the neck into three distinct zones based on anatomical landmarks.5 (See Zooming in on the neck’s zones.) • Zone I, which spans the space between the clavicles and the cricoid cartilage, contains the common carotid, vertebral, and subclavian arteries.1,5 The apices of the lungs extend into this region, along with the trachea, esophagus, thoracic duct, and nerves comprising the brachial plexus.1,3 The aortic arch is in close proximity to this region. • Zone II is anatomically designated between the cricoid cartilage and the angle of the mandible.1,3,5 It contains the larynx, pharynx, base of the tongue, internal and external carotid arteries, jugular veins, spinal cord, thyroid gland, and the cranial nerves (CN) lower in the brainstem, CN X, XI, and XII. • Zone III, the space between the angle of the mandible and the base of the skull, contains the same neck structures as zone II, but some are slightly more superficial as they ascend. Just because the patient experiences an injury to zone II doesn’t mean the wound can’t track down www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anatomy of critical pathways sternocleidomastoid posterior belly of digastric superficial temporal artery maxillary artery external carotid artery posterior auricular artery
internal jugular vein occipital artery hypoglossal nerve
facial artery lingual artery stylohyoid
descending branch of hypoglossal nerve internal carotid artery superior laryngeal nerve deep cervical lymph nodes descending cervical nerve
anterior belly of digastric mylohyoid nerve to thyrohyoid sternohyoid internal laryngeal nerve superior thyroid artery
thyrohyoid ansa cervicalis
spinal part of accessory nerve
external laryngeal nerve thyroid cartilage
superior thyroid vein
cricoid cartilage
common carotid artery
superior belly of omohyoid isthmus of thyroid gland
anterior jugular vein external jugular vein sternothyroid From Snell RS. Clinical Anatomy. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2003.
into zone I and involve high thoracic structures or track up and involve zone III structures. To avoid classifying the patient as not emergent or not a surgical emergency based on the location of the injury, some authors suggest classifying all patients with a neck injury as potential surgical emergencies. Some recommend using a “no zone” algorithm or dividing the neck into triangles, being aware that the most vital structures are located in the anterior www.Nursing2014.com
triangle.1 The anterior triangle is bordered anteriorly by the midline, posteriorly by the sternocleidomastoid muscle, and superiorly by the lower edge of the mandible.2 Clinical decisions Any patient presenting for treatment after a traumatic injury such as a penetrating injury to the neck should be evaluated according to guidelines established by the American College of Surgeons, Society of
Trauma Nurses, and the Emergency Nurses Association. These are the Advanced Trauma Life Support, Advanced Trauma Care for Nurses, and Trauma Nursing Core Course guidelines, respectively.4,6,7 The general recommendations are outlined here. Nurses should pay close attention to the airway, assessing for signs and symptoms that could indicate an airway injury, including subcutaneous emphysema, wound bubbling, hoarseness, or stridor. These could October l Nursing2014 l 39
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
indicate direct injury to the upper airway or to the nerves innervating the glottis. Because these signs and symptoms are considered definitive signs of airway injury, immediate endotracheal intubation is indicated to secure the airway. If the injury impairs the integrity of the larynx or trachea, an emergent cricothyroidotomy or tracheostomy could be indicated, depending on the patient’s clinical status.8 Because the patient must be able to cough to clear secretions and blood that have moved into the airway, the procedure is typically done with minimal sedation, making it potentially difficult for the healthcare team.8 Any signs indicating a vascular injury warrant immediate airway stabilization and transfer to the OR for surgical exploration and repair. These include: • obvious hemorrhage • pulsatile bleeding • evidence of an expanding hematoma • a bruit or thrill over the carotid arteries • asymmetrical arterial pulses.
However, it’s important to remember that the presence of adequate pulses doesn’t rule out the possibility of a vascular injury.1 Because zone I injuries can involve the mediastinum and vascular injuries can result in significant hemorrhage and be difficult to control, critical resources include a cardiothoracic surgeon and perfusionist. They should be made aware of the patient and the possibility of their involvement in the patient’s care. Due to the close proximity of the aortic arch and innominate vessels, cardiopulmonary bypass may be needed to repair the injury.9 These wounds, unlike many others, shouldn’t be explored within the trauma bay; the OR is the appropriate location for surgical exploration and instrumentation because of its many resources.4 Immediate interventions After the initial trauma assessment has been performed, the nurse should insert another large-bore peripheral venous access device in the contralateral upper extremity
Zooming in on the neck’s zones
40 l Nursing2014 l October
and remove the one in the pulseless extremity to avoid further injury.1 Specimens that should be obtained and sent to the lab include a complete blood cell count, basic metabolic panel, coagulation panel, urine drug screen, and a type and crossmatch. Because the neck is a highly vascular region, a penetrating neck injury can quickly cause significant blood loss. Having typed and crossmatched blood on hand will ensure the patient has the most effective oxygen transport system available if needed to perfuse vital organs. A previous standard, based on older wartime experiences, suggested that a patient whose platysma muscle had been penetrated should immediately have surgical exploration with laryngoscopy and esophagoscopy.9 Today, the standard of care has shifted from immediate surgical exploration for all patients to what’s known as the Mansour Algorithm for penetrating neck injuries.10 Several other care pathways take into consideration the extent and location of the injury. Stable patients with zone I or III injuries require angiography to assess the integrity of blood vessels and other structures in the neck.9 Computed tomography with angiography may be needed to help identify the location of the injured vessel because obtaining a comprehensive clinical assessment is difficult. For vascular injuries in zone I, achieving proximal control of the vessel may be difficult because, as the injury occurs, vasospasm and vasoconstriction impair the surgeon’s ability to see and clamp injured vessels. Most injuries in zone II requiring surgery are immediately obvious to the surgeon. Stable patients with zone II injuries that don’t require surgery are typically managed by serial assessments and observation.9,11 www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
To avoid neurologic complications, most vascular injuries should be surgically repaired under anesthesia in the OR as soon as possible. The exceptions to this rule are the vertebral artery and the major venous vessels, which can be safely ligated in the OR without risking neurologic deficits.9 To temporarily stabilize a hemorrhaging wound in a patient waiting for the OR, the surgeon may insert a urinary drainage catheter through the wound tract and inflate the balloon to tamponade the bleeding until the patient can reach the OR for definitive closure.12 Ongoing assessment and intervention The literature presents some conflicting recommendations about whether or not patients with penetrating neck injuries need a cervical spinal collar. The Eastern Association for the Surgery of Trauma’s guideline reports cervical spine immobilization is needed only when a neurologic deficit is present or a proper physical exam can’t be performed due to the effects of mindaltering substances such as alcohol, change in mental status, or unconsciousness.1,3,13 The nurse must exercise extreme vigilance with these patients, and when in doubt, err on the side of caution and not remove the cervical collar without consulting with the trauma team. Because many physiologic centers affecting the cardiovascular system are located in close proximity to the carotid arteries, the nurse can anticipate that an intra-arterial catheter may be inserted to allow direct measurement of the patient’s BP. The care providers must maintain a high index of suspicion for even minor neck wounds because of the potential for rapid deterioration and fatal outcomes. Patients who don’t require immediate surgical intervention should be admitted into the ICU for close observation. www.Nursing2014.com
Any signs indicating a vascular injury warrant immediate airway stabilization and transfer to the OR. Any patient with a suspected venous injury should be positioned with his or her head as low as possible, and gauze impregnated with petroleum jelly should be applied over the wound to help decrease the risk of a venous air embolism.1 Patients with a penetrating neck injury require frequent assessments of their airway not only for patency but also for the airway’s neurovascular status. The nurse can anticipate performing frequent assessments of the patient’s ability to handle secretions as well as to phonate. A change in pitch, quality, or tone of voice could indicate a nerve injury or palsy caused by compression due to an expanding hematoma. If any changes in physical assessment occur, the surgeon should be notified immediately. Assessing bilateral breath sounds and the work of breathing can help to
identify a developing pneumothorax or damage to the phrenic nerve that’s causing unilateral diaphragmatic paralysis. Nurses can assess the cardiovascular system by ensuring perfusion is adequate distal to the injury. The carotid arteries must be auscultated for bruits and palpated for thrills as a means of continuous assessment and monitoring. Assessing mentation, pupillary light reflexes, and cranial nerve function provides valuable information about the integrity of the vessels supplying and draining the cranium. Injury or compression of an expanding hematoma to the baroreceptors or carotid sinuses could have a profound impact on vasomotor tone and may require inotrope or vasopressor support until that injury can be repaired. Getting closure Mr. G is found to have a stab wound to zone I of the right side of the neck with a probable downward angle on the wound. Suspecting a pneumothorax, the nurse preps the patient for chest tube insertion. Upon insertion of the chest tube, 400 mL of bright red blood drains into the collection chamber. Almost immediately the heart rate begins to normalize, Spo2 levels begin to climb, and BP improves slightly. Because of the persistent absence of palpable pulses and a capillary refill time of more than 5 seconds in the right upper extremity, Mr. G is transported to the angiography suite, where a subclavian artery dissection is discovered. Because percutaneous transcatheter embolization couldn’t be performed due to the extent of his injuries, he’s transferred to the OR for definitive repair. The wound is irrigated and closed without further issues. The patient is transported to the postanesthesia care unit before he’s admitted to the step-down unit for monitoring. October l Nursing2014 l 41
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Mr. G makes a full recovery without complications. His chest tube is removed on post-op day 3 and he’s discharged the following morning. Because of the healthcare team’s knowledge about penetrating neck injuries and the structures associated with specific neck zones and their ability to perform an accurate assessment, this patient’s injuries were rapidly identified and corrected. He was subsequently discharged without complications or permanent injury. ■ REFERENCES 1. Newton K. Penetrating neck injuries. UpToDate. 2013. http://www.uptodate.com 2. Newton K. Initial evaluation and management of penetrating neck injuries: initial evaluation and
>
management. UpToDate. 2014. http://www. uptodate.com. 3. Alterman DM, Daley BJ, Selivanov V. Penetrating neck trauma. Medscape. 2012. http://emedicine. medscape.com/article/433306-overview. 4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual. 8th ed. Chicago, IL: American College of Surgeons; 2008. 5. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma. 1979;19(6): 391-397. 6. Society of Trauma Nurses. Advanced Trauma Care for Nurses. Lexington, KY: Society of Trauma Nurses; 2008. 7. Emergency Nurses Association. Trauma Nursing Core Course. 6th ed. Des Plaines, IL: Emergency Nurses Association; 2007. 8. Preston T, Fedok FG. Blunt and penetrating trauma to the larynx and upper airway. Oper Tech Otolaryngol. 2007;18(2):140-143. 9. LeBoeuf HJ, Quinn FB. Penetrating neck trauma. In: Quinn FB, ed. Dr. Quinn’s Online Textbook of Otolaryngology: Grand Rounds Archive; 1999. http:// www.utmb.edu/otoref/Grnds/Pen-necktrauma-9901/Pen-neck-trauma-9901m.pdf.
10. Mansour MA, Moore EE, Moore FA, Whitehill TA. Validating the selective management of penetrating neck wounds. Am J Surg. 1991;162 (6):517-520; discussion 520-521. 11. Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J. 2008;25(11):711-715. 12. Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg. 2012;99 (suppl 1):149-154. 13. Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008;64(5):1392-1405. http:// www.east.org/resources/treatment-guidelines/ penetrating-zone-ii-neck-trauma. Mark McGraw was formerly a staff nurse at Christiana Care Health System in Newark, Del. Currently, he’s a full-time student in the MSN program at Villanova University in Villanova, Pa., with a concentration in nurse anesthesia. The author and planners have disclosed no potential conflicts of interest, financial or otherwise. DOI-10.1097/01.NURSE.0000453724.85369.e3
