![]() Gastrograffin may be safer as it is water-soluble and leakage is less likely to cause a chemical mediastinitis Gastrograffin and barium studies may be performed.Contrast esophogram with poor sensitivity for injury ( Asensio 1997).Findings: pneumomediastinum, retropharyngeal air.May suggest perforation but are not sensitive (cannot rule out injury).Plain X-rays ( Thoma 2008, Bryant 2007).Soft signs: hematemesis, dysphagia, subcutaneous emphysema, hoarseness, cough.If direct pressure cannot control bleeding, placement of a foley catheter and balloon inflation may be successful in tamponade of bleeding as a temporizing measure ( Navsaria 2006).If possible, start access on the contralateral side to the injury.Application of direct pressure is often successful in controlling bleeding.Vascular injuries are the most common cause of mortality ( Kendall 1998).DO NOT PROBE wounds with active bleeding as may dislodge clot.Injuries that transverse zones can also cause PTX.Zone I injuries can result in pneumothorax (PTX).Make airway visualization more difficult.Cervical spine immobilization is unnecessary unless the trajectory suggests direct spinal cord injury and may be harmful ( Vanderlan 2009, Haut 2010, Stuke 2011, Lustenberger 2011, Theodore 2013).Consider awake intubation or ketamine facilitated intubation Paralysis may theoretically cause airway obstruction by relaxation of muscles (though this is not born out in the literature).Bag valve mask (BVM) ventilation should be minimized as it can cause dissection of air into the neck and worsen airway distortion.Consider a smaller tube size to minimize secondary injury. Careful/gentle placement of the ETT is necessary when the patient has a partial transection of the trachea.cricothyroidotomy) if laryngoscopy or endotracheal tube placement fails Have the neck prepared for front of neck access (i.e.Hematemesis and hemoptysis can make visualization of the airway structures challenging.Expanding hematomas can cause dynamic airway compromise.Early airway control should be considered in patients with hard signs.Tracheobronchial Injury occurs in up to 20% of patients ( Kendall 1998).Can apply direct pressure to bleeding wounds en route.Delays should only occur for securing the unstable airway.Hard signs associated with 90% rate of major injury ( Evans 2018).Any patient with hard signs of injury should be expeditiously brought to the operating room for further management. ![]() Focus on immediate life-threats: exsanguination and asphyxiation from airway obstruction.WTA Management Algorithm for Penetrating Neck Injury (Sperry 2013)
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