257. Trauma to the Neck

General

Roon & Christenen classification: 3 zones. Zone I: clavicle to cricoid cartilage. Includes typical neck structure with lungs, thoracic duct. Vascular control difficult. If OR required, will need thoracic surgical approach usually. Zone II: cricoid cartilage to angle of mandible. Both proximal and distal vascular control can be controlled early. Not necessarily needing OR exploratory though likely will extensive wound, transcervical trajectory. Zone III: angle of mandible to base of skull. Treat as cranial injury. Vascular injury primarily the main cover. Selective, nonoperative management. Exploratory surgery not indicated.

Other classification involves anterior and posterior: Anterior triangle: posterior landmark is sternocleidomastoid muscle, clavicle is inferior landmark. Posterior triangle: posterior landmark is trapezius muscle – more favorable outcome with injuries to posterior than anterior triangle.

Most superficial structure beneath skin/subcutaneous tissue is the platysma muscle. Important landmark for penetrating neck trauma.

Hard signs: usually associated with significant injury: active hypotension, active arterial bleeding, diminished carotid pulse, expanding hematoma, thrill/bruit, lateralizing signs, hemothorax > 1L, air bubbling in wound, hemoptysis, hematemesis, tracheal deviation.

Soft signs: hypotension in the field, history of arterial bleeding, unexplained bradycardia, non expanding hematoma, stridor/hoarseness (though can be considered hard signs as well), vocal cord paralysis, subcutaneous emphysema, 7th CN injury.

Airway: intubate early. Better than delay with difficult intubation with patient in respiratory distress/distorted airway. Likely needing intubation: acute respiratory distress, airway obstruction from blood/secretions, massive subcutaneous emphysema, tracheal shit, AMS, expanding neck hematoma.

Breathing: consider hemo/pneumothorax in Zone I.

Circulation: direct pressure over bleeding; no clamping (can cause neuro injuries).

Disability: normal neuro exam with isolated penetrating trauma does not need C-spine immobilization.

Penetrating Trauma

Stab, GSW, shotgun, sharp objects. If platysma violated, assume significant injury. Never probe. Surgical consult likely needed. If hemodynamic unstable or obvious aerodynamic injury, immediate surgery. CTA for vascular injury; you can’t r/o esophageal or tracheal injury with CTA alone. Ultrasound (doppler or otherwise) pretty much useless.

Venous Air Embolism: can cause profound shock or cardiac arrest. If considering, place patient head down, left lateral decubitus position. This position tries to accumulate air into apex of right ventricle. After this, consider aspiration with either ultrasound guidance or thoracotomy.

Blunt Trauma

Clothesline injuries, direct blows, handlebars, near hangings (probably most common). Symptoms often minimal or delayed. Anatomic triangles are probably more important than zones. Think vascular and larynx injuries. Do CTA over CT soft tissue neck. When considering intubation, may consider whether or not to do paralytic agent due to paralysis may result in decreased muscle tone.

Cricothyroidoctomy should be avoided because it may worsen laryngeal injury. Consider vertebral artery injuries with cervical hyperextension, excessive contralateral rotation or both. 50% of dissections are asymptomatic initially. Neuro symptoms often delayed. Wallenburg syndrome: lateral medullary infarction syndrome: ipsilateral facial loss of pain/temp, isolated loss of CN V, IX, X, and XI, cerebellar ataxia, Horner’s syndrome, and body contralateral loss of pain/temp. If blunt vascular injury confirmed, will need to anticoagulant to prevent stroke or propagation. CTA better than MRA for vascular dissections. Consider endovascular stenting for severe dissection.

Thyroid hematomas can slowly expand and eventually cause airway compromise.

For asymptomatic patients, likely need to observe for at least 2 hours, more likely 4 hours before discharge.

When to consider CTA on neck trauma: ATLS 9th edition: C1-C3 fractures, fractures with subluxation, fracture thru foramen transversium. EAST: Neuro deficits, blunt injury with significant epistaxis, asymptomatic with RF: GCS < 8, petrous bone fracture, diffuse axonal injury, C1-C3 fracture and fracture through foramen transverse, Leforte Fractures. Denver Criteria:

Strangulation

Complete if freely suspended. Incomplete is everything else. If fall > length of body, likely cervical fracture causing likely Hangmans fracture with cervical cord transection leading to death.

Constriction causes jugular venous obstruction leading to brain ischemia leading to LOC and eventually death. Airway compromise isn’t main cause for death/LOC. Traumatic edema of larynx and supraglottic tissue can lead to airway compromise. Should consider with painful swallowing, severe hoarseness, stridor. Watch for pulmonary complications which is the most common cause of in-hospital mortality.

Tardieu spots: petechial hemorrhage seen in conjunctiva, mucus membranes, skin.

Esophageal Injuries

Most frequently missed injury in neck trauma. CTA does not diagnosis. Consider contrast esophagraphy with water-soluble contract (gastrograffin bad for lungs; barium bad for GI and mediastinum; consider omnipaque, ultraist, hexabrix). Barium more sensitive but dangerous with extravasation. Flexible endoscopy follows negative contrast study. Combo has sensitivity of 100%. If suspicious, start broad spectrum IV abx (Zosyn) and make NPO. Consider endoscopied placed NG for gastric content. Small contained injuries can be managed with observation/NPO.

Laryngotracheal Injuries

Cricoid cartilage is only complete ring in trachea. Calcification of laryngeal cartilage begins at teenage years leading to higher mortality in kids. Pain with tongue movement or rotation of head can be related to hyoid bone or laryngeal cartilage injury. Diagnosis with laryngoscopy. CT pretty good at detecting though.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 257: Trauma to the Neck

Rosens, Chapter 37: Neck Trauma

Which Neck Injuries Require Vascular Imaging, Eric Martin, 2015 Managing Medical Emergencies, EMedHome

CrashingPatient.com, Neck Trauma

Blunt Neck Trauma, William Mallon, AAEM Scientific Assembly 2017

257. Trauma to the Neck