Platypus identical triplets, Huey, Dewey, and Louie, walk into a bar and proceed to start a riot over whether or not they are mammals given that platypodes lay eggs. 911 is called. The three are brought to the ER for injuries sustained above the clavicles defending the honor of their species:
 

 

    Huey is stabbed with a switchblade between his right trapezius and the clavicle
    Dewey is shot in the left posterior neck at the level of his thyroid cartilage
    Louie suffered an uppercut-style blow to the midline jaw with a broken bottle

 
How do you divide the anatomy of the neck to help guide emergent management of penetrating injuries?

 
The neck can be divided into two triangles.
The posterior triangle is demarcated by

    Posterior border: trapezius muscle
    Anterior border: posterior aspect of the SCM muscle
    Inferior border: clavicle

The anterior triangle is demarcated by

    Posterior border: anterior aspect of the SCM muscle
    Anterior border: anatomic midline
    Superior border: mandible

 
The anterior triangle can be further divided into 3 Zones. What are the borders of these Zones?

“Fig1: Three-dimensional volume rendering technique (3D VRT) of MDCTA performed on a young male victim of a stab wound to the neck…”, in “Imaging assessment of penetrating injury of the neck and face” by Offiah C, and Hall E, via OPENi

 

    Zone I: Clavicles to the inferior rim of the cricoid cartilage
    Zone II: Superior edge of the cricoid to the angle of the mandible
    Zone III: Angle of the mandible to the base of the skull

 

 
 
 
Initially, they all have the same vital signs:
T 38C HR 95 BP 128/88 RR 22 O2 sat 98% on room air
 
Huey, the one with the switchblade in the right side of his neck just above the clavicle, starts to have air bubbling up through the bleeding in his neck.
 
When evaluating the primary survey and secondary surveys of a patient with penetrating trauma to the neck, what findings indicate that the patient needs immediate operative interventions?
 

    “Hard signs” of vascular injury:

      Active or pulsatile hemorrhage
      Shock unresponsive to volume resuscitation
      Expanding hematoma
      Presence of bruit or thrill
      Diminished distal pulses
      Focal neurologic deficit
    Other indications:

      Air bubbling from wound
      Hematemesis
      Odynophagia
      Subcutaneous emphysema
      Blood in saliva or aspirate

 
For Huey given that he has air bubbling up through a wound in Zone I, he needs immediate operative management for what turns out to be a jugular-tracheal communication.

 
 
Dewey, the one who was shot in the neck, only has an entrance wound on the left. On exam, ABCs are intact and you want to give him a GCS of 15 but realize that he can’t raise his left arm. You complete the secondary survey only to confirm the single entry point in the left neck laterally at the level of the thyroid. Dewey’s neurologic exam is also concerning for decreased tactile sensation in his left arm and leg, and diminished response to painful stimuli in his right fingers and toes.
 
What is the etiology of Dewey's constellation of findings on secondary survey?
 
Brown-Séquard Syndrome! This hemitransection of the spinal cord results in the following sensory changes below the level of the injury:

    Ipsilateral hemiplegia
    Ipsilateral loss of tactile sensation
    Ipsilateral loss of proprioception
    Contralateral loss of pain sensation
    Contralateral loss of temperature sensation

 

 
 
Louie, the last platypus standing and the one who was struck under the chin with an empty bottle is brought in by EMS in a cervical collar.
 
What are the pro's and con's of pre-hospital placement a c-collar on a patient with penetrating neck trauma?
 
Pro’s:

    Ensure cervical spine stabilization
    Potential pressure on any developing hematoma

 
Con’s:

    Prevents visualization of any expanding hematoma
    Applies further pressure to an air with fascia-lined, minimally expandable compartments, potentially worsening distortion of internal anatomy (read may increase tracheal shift?)
    Makes a potentially challenging airway, even more so with a cervical collar on.
    In the absence of altered mental status, focal neurologic findings, and cervical spine tenderness, there has been no retrospective value to the placement of pre-hospital c-collars.

 

 
 
When evaluating Louie's laceration without probing it, you notice that it does not penetrate his platysma. Does Louie need imaging for his penetrating neck injury?
 
No! In general, neck injuries of any zone that do not penetrate the platysma do not need operative management nor advanced imaging.
 
 
Bibliography:
Mayglothling, J. Chapter 027. Penetrating Neck Trauma. In A. B. Wolfson, R. L. Cloutier, G. W. Hendey, L. J. Ling, C. L. Rosen, & J. Schaider (Eds.), Harwood-Nuss’ Clinical Practice of Emergency
Medicine (6th ed.). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=booktext&D=books2&AN=01817268/6th_Edition/3&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/EDITORS%5b1%5d.
 
Offiah, C., & Hall, E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging [serial online]. 2012; 3: (5), 419-431. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22945428.

4 Responses to Platypodes Walk into a Bar Fight

  • RL says:

    Why are you abusing platypii? 🙁 Poor platypii .

    • Dan says:

      Well, they should start bar fights! More accurately though we were trying to think of a pun to help remember the importance of the platysma in evaluation of penetrating neck trauma: platypus…platysma…?

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