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

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



Download


One Comment





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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