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

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)