November 25, 2019

Episode 173.0 – Blunt Neck Trauma

12 minutes

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

...more

View all episodes

By Core EM

4.5

237237 ratings

November 25, 2019

Episode 173.0 – Blunt Neck Trauma

12 minutes

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

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.

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

...more