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 OverviewBlunt neck trauma comprises 5% of all neck traumaMortality due to loss of airway more so than hemorrhageMechanismMVCs 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, fallsInitial Management/Primary SurveyAirwayEvaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromiseEarly aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edemaAssume a difficult airway BreathingSupplemental oxygenAssess for bilateral breath sounds Can use bedside US to evaluate for pneumothorax or hemothoraxCirculationAssess for open wounds, bleeding, hemorrhage IV accessDisabilityMaintain C-spine immobilization Calculate GCSLook for seatbelt signSecondary SurveyEvaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultationPerform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)Types of InjuriesVascular injuryOverviewCarotid arteries (internal, external, common carotid) and vertebral arteries injuredMortality rate ~60% for symptomatic blunt cerebral vascular injuryMechanismHyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulationMorbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transectionsClinical FeaturesMost patients are asymptomatic and do not develop focal neurological deficits for daysif 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 2016Diagnostic TestingGold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)<80% sensitive but 97% specificAlso 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 loadManagementAntithrombotics vs. interventional repair based on BCVI grading systemInvolve consultants early: trauma surgery, neurosurgery, vascular surgery, neurologyAll patients with blunt cerebral vascular injury will require admissionTintinalli 2018Pharyngoesophageal injury  OverviewRare in blunt neck traumaIncludes hematomas and perforations of both pharynx and esophagusMechanismSudden acceleration or deceleration with hyperextension of the neckEsophagus is thus forced against the spineClinical FeaturesDysphagia, odynophagia, hematemesis, spitting up bloodTenderness to palpationSC emphysemaNeurological deficits (delayed presentation)Infectious symptoms (delayed presentation)Diagnostic TestingEsophagography 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 agentMDCTAPlain films of neck and chest Findings such as pneumomediastinum, hydrothorax, or retropharyngeal air may suggest perforation but are not sensitiveManagementAll pharyngoesophageal injuries receive IV antibiotics with anaerobic coverageParenteral/ enteral nutritionNGT should only be placed under endoscopic guidance to avoid further injuryMedical management vs. surgical repair depending on extent of injurySurgical repair for esophageal perforations or pharyngeal perforations >2cmInvolve consultants early: trauma surgery, vascular surgery, otolaryngology, gastroenterologyAll patients with blunt cerebral vascular injury will require admissionLaryngotracheal injury  OverviewOccurs in >0.5% of blunt neck traumaIncludes hyoid fractures, thyroid/ cricoid cartilage damage, cricotracheal separation, vocal cord disruption, tracheal hematoma or transectionMechanismAssault, clothesline injuries, direct blunt force from MVCs compressing the larynx between a fixed object and the spineClinical FeaturesPatients are often asymptomatic at first and then develop airway edema and/or hematoma resulting in airway obstructionChildren are at higher risk for airway compromise due to less cartilage calcificationsDiagnostic TestingFlexible fiberoptic laryngoscopy (FFL) to assess airway patency and extent of intraluminal injuryMDCTAObtain 1-mm cuts of larynx and perform multiplanar reconstructions Consider POCUS to detect laryngotracheal separationPlain films of neck and chestPoor sensitivity for penetrating neck trauma injuriesCan show extraluminal air, fracture or disruption of cartilaginous (e.g. larynx) structures ManagementWhen securing airway, use an ETT that is one size smaller due to likelihood of airway edemaConservative management (IV antibiotics, steroids, observation) vs. surgical repairGrades III, IV, and V laryngotracheal injuries as defined by Schaefer and Brown’s classification system require ORTintinalli 2018Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology Cervical spine/ spinal cord injury  See chapter for spinal traumaDispositionAdmit symptomatic patients to monitored settingGiven delayed symptoms, consider monitoring patients who are asymptomatic on arrivalSerial exams for worsening dyspnea, dysphonia, stridor, drooling, bruits, focal neuro deficitsOnly discharge after ruling out airway threat, neurological deficit, vascular injury, or suicidal/ homicidal ideationMonitor asymptomatic patients on home anticoagulation in ED for at least 6 hours from trauma to rule out delayed neck hematomaSocial work and/or psychiatry for patients in whom you suspect suicide risk or domestric violence, look for other signs of self harmTake Home PointsAggressive early airway management for unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edemaInvolve 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 anticoagulationRemember to evaluate for concomitant injuriesPsychiatric evaluation for all attempted suicidesReferencesBromberg, 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;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