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

November 25th, 2019 Download Leave a Comment Tags:

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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