You have been called to the Emergency Room to review a previously well adult male who has sustained a penetrating injury to the root of the neck.
- a) Describe the anatomy of the root of the neck on the left side describing the clinically important structures that may be injured. (50% marks)
- b) Outline the issues specific to management of a penetrating neck injury. (50% marks)
Answer and interpretation
a) Describe the anatomy of the root of the neck on the left side describing the clinically important structures that may be injured. (50% marks)
- The root of the neck is the junction between the thorax and the neck. It opens into, and is the cervical side of, the superior thoracic aperture, through which pass all structures going from the head to the thorax and vice versa. The root of the neck is bound laterally by the first rib, anteriorly by the manubrium, and posteriorly by the T1 vertebrae.
- From anterior to posterior, the major contents are:
- Subclavian artery and branches
- vertebral artery
- internal thoracic artery
- thyrocervical trunk
- costocervical trunk
- Subclavian vein and tributaries (EJV)
- Vagus nerve
- Recurrent Laryngeal nerve Dome of pleura
- Brachial plexus
- Lymphatics and thoracic duct
- Phrenic nerve
- Sympathetic chain, stellate ganglion
- Scalene muscle.
b) Outline the issues specific to management of a penetrating neck injury. (50% marks)
Requires management at a trauma centre with appropriate expertise. May require multiple speciality input – interventional radiology, ENT, vascular, cardiothoracic.
- The possibility of laryngeal/ tracheal injury and the risk of intubating the “false airway passage”.
- Consider tracheostomy under local anaesthesia.
Urgent surgical exploration required for haemodynamic compromise, expanding or pulsatile haematoma, extensive subcutaneous emphysema, stridor, or neurological deficit with intra op bronchoscopy/ endoscopy/ angiography if available.
If no indication for urgent surgical exploration requires CT angiography (or equivalent) with close observation in ICU +/- flexible laryngoscopy +/- endoscopy +/- oral contrast swallow study.
- Pass rate: 27%
- Highest mark: 7.4
Additional Examiners’ Comments:
- Most candidates were not aware of the issues and management priorities associated with this type of trauma.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.