Episode 173.0 – Blunt Neck Trauma
We go into one of the more complex injuries – blunt neck trauma.
Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blunt_Neck_Injuries.mp3
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Tags: Trauma
Show Notes
Overview
Blunt neck trauma comprises 5% of all neck trauma
Mortality due to loss of airway more so than hemorrhage
Mechanism
MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact
Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)
Direct blows: assault, sports, falls
Initial Management/Primary Survey
Airway
Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise
Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
Assume a difficult airway
Breathing
Supplemental oxygen
Assess for bilateral breath sounds
Can use bedside US to evaluate for pneumothorax or hemothorax
Circulation
Assess for open wounds, bleeding, hemorrhage
IV access
Disability
Maintain C-spine immobilization
Calculate GCS
Look for seatbelt sign
Secondary Survey
Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation
Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)
Types of Injuries
Vascular injury
Overview
Carotid arteries (internal, external, common carotid) and vertebral arteries injured
Mortality rate ~60% for symptomatic blunt cerebral vascular injury
Mechanism
Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation
Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections
Clinical Features
Most patients are asymptomatic and do not develop focal neurological deficits for days
if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)
specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)
Tintinalli 2016
Diagnostic Testing
Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)
<80% sensitive but 97% specific
Also images aerodigestive tracts and C-spine (unlike angiography)
Followed by Digital Subtraction Angiography (DSA) for positive results or high suspicion
Angiography is invasive, expensive, resource-intensive, and carries a high contrast load
Management
Antithrombotics vs. interventional repair based on BCVI grading system
Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology
All patients with blunt cerebral vascular injury will require admission
Tintinalli 2018
Pharyngoesophageal injury
Overview
Rare in blunt neck trauma
Includes hematomas and perforations of both pharynx and esophagus
Mechanism
Sudden acceleration or deceleration with hyperextension of the neck
Esophagus is thus forced against the spine
Clinical Features
Dysphagia, odynophagia, hematemesis, spitting up blood
Tenderness to palpation
SC emphysema
Neurological deficits (delayed presentation)
Infectious symptoms (delayed presentation)
Diagnostic Testing
Esophagography with water-soluble contrast (e.g. Gastrograffin)
If negative contrast esophagography, obtain flexible endoscopy (most sensitive)
Combination of contrast esophagography + esophagoscopy has sensitivity close to 100%
Swallow studies with water-soluble agent
MDCTA
Plain films of neck and chest
Findings such as pneumomediastinum, hydrothorax, or retropharyngeal air may suggest perforation but are not sensitive
Management
All pharyngoesophageal injuries receive IV antibiotics with anaerobic coverage
Parenteral/ enteral nutrition
NGT should only be placed under endoscopic guidance to avoid further injury
Medical management vs. surgical repair depending on extent of injury
Surgical repair for esophageal perforations or pharyngeal perforations >2cm
Involve consultants early: trauma surgery, vascular surgery, otolaryngology, gastroenterology
All patients with blunt cerebral vascular injury will require admission
Laryngotracheal injury
Overview
Occurs in >0.5% of blunt neck trauma
Includes hyoid fractures, thyroid/ cricoid cartilage damage, cricotracheal separation, vocal cord disruption, tracheal hematoma or transection
Mechanism
Assault, clothesline injuries, direct blunt force from MVCs compressing the larynx between a fixed object and the spine
Clinical Features
Patients are often asymptomatic at first and then develop airway edema and/or hematoma resulting in airway obstruction
Children are at higher risk for airway compromise due to less cartilage calcifications
Diagnostic Testing
Flexible fiberoptic laryngoscopy (FFL) to assess airway patency and extent of intraluminal injury
MDCTA
Obtain 1-mm cuts of larynx and perform multiplanar reconstructions
Consider POCUS to detect laryngotracheal separation
Plain films of neck and chest
Poor sensitivity for penetrating neck trauma injuries
Can show extraluminal air, fracture or disruption of cartilaginous (e.g. larynx) structures
Management
When securing airway, use an ETT that is one size smaller due to likelihood of airway edema
Conservative management (IV antibiotics, steroids, observation) vs. surgical repair
Grades III, IV, and V laryngotracheal injuries as defined by Schaefer and Brown’s classification system require OR
Tintinalli 2018
Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology
Cervical spine/ spinal cord injury
See chapter for spinal trauma
Disposition
Admit symptomatic patients to monitored setting
Given delayed symptoms, consider monitoring patients who are asymptomatic on arrival
Serial exams for worsening dyspnea, dysphonia, stridor, drooling, bruits, focal neuro deficits
Only discharge after ruling out airway threat, neurological deficit, vascular injury, or suicidal/ homicidal ideation
Monitor asymptomatic patients on home anticoagulation in ED for at least 6 hours from trauma to rule out delayed neck hematoma
Social work and/or psychiatry for patients in whom you suspect suicide risk or domestric violence, look for other signs of self harm
Take Home Points
Aggressive early airway management for unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology
Victims of blunt cerebral vascular injury may present completely asymptomatic but develop delayed neurological symptoms; close observation and monitoring is recommended especially for patients on home anticoagulation
Remember to evaluate for concomitant injuries
Psychiatric evaluation for all attempted suicides
References
Bromberg, William. et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010.
Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540–545; discussion 545–546.
Joshua AA. Neck Trauma, Blunt, Anterior. In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edition. Philadelphia, PA: Wolters Kluwer; 2015; 738-739.
Tintinalli, J., Stapczynski, J. Stephan, editor, Ma, O. John, editor, Yealy, Donald M., editor, Meckler, Garth D., editor, & Cline, David, editor. (2018). Tintinalli’s emergency medicine : A comprehensive study guide (9th ed.).
Walls, R., Hockberger, Robert S., editor, & Gausche-Hill, Marianne, editor. (2018). Rosen’s emergency medicine : Concepts and clinical practice (Ninth ed.).
Advanced trauma life support. (2018). 10th ed. Chicago, IL: American College of Surgeons.
Special thanks to Sana Maheshwari, MD
NYU Bellevue Emergency Medicine Residency PGY3
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