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 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   Read More