Presented by Dr. T Horan.
30 year old male gets dropped off in front of the ED bleeding from his neck. You are the first doctor to see the patient.
What you seen when you walk into the room:
30 year old male with a towel on the right side of his neck that is soaked with blood and there is blood covering his entire torso and pelvis. Pt is very agitated yelling at you, screaming to not cut off his pants and that he needs his socks. Nursing staff is holding the towel to the patient’s neck and he is screaming you are choking me.
A: Pt is screaming and does not seem to be in any respiratory distress. There is no blood coming from the pt’s mouth.
B: Pt has clear lungs sounds bilaterally
C: You assess the bleeding neck. There is what seems to be a 10 cm by 6 cm laceration that is actively bleeding with one obvious arterial bleeder. The laceration is below the mandible and extends medially diagonally but without crossing the midline and superior to the cricoid cartilage. Pt is still extremely agitated and refuses for you to take vital signs or further examine him. Pt has equal and rapid pulses bilaterally
D: Pt continues to scream not to cut his pants and that he needs socks. Pt keeps sitting up and does not allow you to fully examine him. Pt does not respond appropriately to commands or questions.
E: Pt has no other obvious injuries. The blood on the torso and pelvis seem to be all from the neck injury.
Trauma team still has not come to the trauma bay.
We decided to intubate the patient so that we can fully assess him, that he does not further injure himself and for airway control. We were intubating the patient as trauma team arrived. Pt was successfully intubated and trauma team was able to further assess the patient.
Morning Report discussion:
Zones of the Neck:
There are three zones of the neck
Zone I is between the sternal notch and the cricoid cartilage. This zone contains the proximal subclavian, vertebral and carotid arteries, apices of the lung, trachea, esophagus, thoracic duct, thyroid and parathyroid glands.
Zone II is between the cricoid cartilage and angle of the mandible. It contains the carotid and vertebral arteries, trachea, larynx, esophagus, spinal cord and vagus and recurrent laryngeal nerves.
Zone III is above the angle of the mandible and it contains the pharynx, salivary glands, distal carotid and vertebral arteries and several cranial nerves.
Zone II injuries, as in our patient, are the most common. They can be surgically explored and direct pressure can be held. Injuries in Zone I and III are more difficult to control and explore. Zone I injuries have the highest mortality because of the involvement of intrathoracic structures and great vessel injuries.
Does the injury penetrate the platysma is the next question that needs to be answered. If not then the injury does not require extensive evaluation and exploration. If it does penetrate the platysma surgical evaluation and exploration is required.