Basics
Description
- Blunt anterior neck trauma may result in various injuries to structures in the neck:
- Vascular:
- Carotid artery injury (internal, external, common carotid)
- Vertebral artery injury
- Intramural hematoma, intimal tear, thrombosis, and pseudoaneurysm
- Hemorrhage or neck hematoma
- Laryngotracheal:
- Laryngeal injuries: Fracture of hyoid bone, thyroid cartilage, cricoid cartilage, cricotracheal separation
- Vocal cord disruption
- Dislocation of arytenoid cartilage
- Tracheal injuries: Hematoma or transection
- Pharyngoesophageal:
- Pharynx: Hematoma, perforation
- Esophagus: Hematoma, perforation
- Nervous system:
- Thoracic sympathetic chain wraps around carotid artery: Disruption can result in Horners syndrome
- Vagus nerve and recurrent laryngeal nerve
- Cervical nerve roots and spinal cord
- Cervical spine:
- Fracture of vertebral body, transverse process, spinous process, etc.
- Dislocation
Etiology
- Motor vehicle accidents (most common cause):
- Unrestrained occupants involved in frontal collisions may strike neck on dashboard or steering wheel: "Padded dash syndrome " ¯
- Shoulder harness (seatbelt) can also cause shearing injury to anterior neck.
- Assault: Blows to anterior neck from fists, kicks, or objects
- "Clothesline injury " ¯:
- Motorcycle, snowmobile, jet ski, or all-terrain vehicle (ATV)
- Drivers strike neck on cord or wire suspended between 2 objects.
- Strangulation
- Head is proportionally larger in children, increasing risk of acceleration " “deceleration injury to neck
- Intraoral blow to soft palate may cause carotid thrombosis (popsicle in mouth of child who falls, pushing the object into soft palate).
Diagnosis
Signs and Symptoms
- Presentation varies depending on mechanism of injury and structures involved:
- Vascular injury:
- Hemorrhage, ecchymosis, edema
- Carotid bruit or thrill (pathognomic for vascular injury)
- Neurologic deficits (often delayed)
- Laryngotracheal injury:
- Voice changes, hoarseness, aphonia
- Dyspnea, inspiratory stridor, labored breathing, "air hunger " ¯
- SC emphysema, tenderness to palpation
- Pharyngoesophageal injury (rarely isolated):
- Dysphagia, odynophagia, hematemesis, blood in saliva
- Tenderness to palpation
- Infection, sepsis (delayed presentation)
- Neurologic injury:
- Central or peripheral nervous system deficits
History
- Detailed history (if patient is able to provide) based on signs and symptoms:
- Cover all structures of the neck, as well as structures outside the neck (neck trauma usually associated with injures to chest, head, etc.)
Physical Exam
- Ensure airway protection and patency.
- Inspect neck for hemorrhage, hematoma, ecchymosis, edema, or distortion of anatomy.
- Auscultate for carotid bruits, stridor.
- Palpate to detect tenderness or SC emphysema.
- Neurologic exam to detect evidence of ischemic event, spinal cord injury, or peripheral nerve damage
- Complete physical exam to detect associated injuries to the chest, abdomen, etc.
Essential Workup
Depends on history and physical exam findings ‚
Diagnosis Tests & Interpretation
Lab
- Type and cross-match
- Baseline CBC
- BUN/creatinine may be needed prior to radiologic testing (contrast with CT or MRI)
Imaging
- Cervical spine and lateral neck radiographs
- Limited value but may show subglottic narrowing, prevertebral soft tissue swelling, SC air, fractured calcified larynx
- CXR to rule out associated injury to thorax (pneumothorax, pneumomediastinum, etc.)
- Carotid duplex US is a noninvasive, rapid screening test for arterial injury:
- Sensitivity as high as 92% in retrospective studies for dissection, operator-dependent, poor visualization above carotid bifurcation
- CT may be used in stable patients to evaluate laryngotracheal injury, cartilage disruption, or cervical spine injury.
- CT angiography:
- Low sensitivity (50%) and high specificity (99%) on initial studies with early-generation CT scanner compared with angiography for carotid and vertebral artery injury, may have improved rates of detection with newer-generation CT scanners
- Magnetic resonance arteriography (MRA):
- Low sensitivity (49%) and high specificity (99%) on initial studies with MRA compared with angiography for carotid and vertebral artery injury
- 4-vessel angiography is considered gold standard for evaluation of arterial injury.
- Indications for angiography:
- Presence of carotid bruit
- Expanding neck hematoma
- Neurologic deficit without intracranial pathology on CT
- Horners syndrome
- Decreased level of consciousness
Diagnostic Procedures/Surgery
- Unstable patients must go directly to surgery.
- Laryngotracheal injuries:
- Fiberoptic laryngoscopy can visualize subglottic airway, facilitate intubation, assess airway patency and injury.
- Esophageal injuries:
- Initial study of choice: Gastrografin swallow study (less pleural irritation with extravasation) or barium swallow study
- Indications for endoscopy:
- Odynophagia
- Hematemesis or blood in saliva
- SC emphysema
Differential Diagnosis
- Peripheral or CNS injury
- Cervical spine injury
- Associated head or thoracic trauma
Treatment
Pre-Hospital
- Airway must be vigilantly monitored:
- Edema or expanding hematoma can progress to airway compromise.
- Orotracheal intubation preferred 1st-line technique for airway control
- Clinical signs of respiratory distress:
- Stridor
- Air hunger
- Labored breathing
- Expanding neck hematoma
- Blind nasotracheal intubation should be avoided:
- Owing to anatomy distortion and risk of hematoma rupture
- Cervical spine must be stabilized.
Initial Stabilization/Therapy
Airway management with cervical spine control: ‚
- Immediate intubation indicated for patients with signs of airway compromise or impending compromise
- Cricothyroidotomy or emergent tracheostomy may be needed if oral intubation is unsuccessful.
- Contraindicated if bruising or hematoma noted over thyroid/cricoid cartilage
- Bleeding into pharynx can be reduced by packing throat with heavy gauze after airway is secured by intubation.
- Unstable patients must go directly to OR.
Ed Treatment/Procedures
- Surgical consultation should be obtained for patients with suspicion of vascular, tracheal, or esophageal injury.
- Immediate surgical repair is required for symptomatic vascular injury, tracheal injury, pharyngeal, or esophageal injury.
- Laryngeal injury may not require immediate surgical repair.
- Anticoagulation is recommended for vascular injuries due to consequent luminal narrowing and thrombosis:
- Results in improved neurologic outcomes
- Requires surgical consultation prior to initiation of therapy
Medication
- Anticoagulation (see above)
- Prophylactic antibiotics recommended in presence of an esophageal injury to prevent abscess formation (anaerobic coverage):
- Cefoxitin: 2 g (peds: 80 " “160 mg/kg/d div. q6h) IV q8h or
- Clindamycin: 600 " “900 mg (peds: 25 " “40 mg/kg/d div. q6 " “8h) IV q8h or
- Penicillin G: 2.4 million U/d (peds: 150,000 " “250,000 U/kg/d) IV q4 " “6h, + metronidazole
- Metronidazole: 1 g load, then 500 mg (peds: 30 mg/kg/d div. q12h) IV q6h
Follow-Up
Disposition
Admission Criteria
- Patients who are symptomatic, have abnormal studies, or have significant blunt trauma mechanism must be admitted and observed for at least 24 hr.
- Patients with suspicion of airway or vascular injury must be admitted to ICU.
Patients on anticoagulation medications should be observed in ED for 6 hr from injury to look for signs of delayed neck hematoma. ‚
Discharge Criteria
Only patients with most trivial injuries who have negative studies may be discharged from ED after thorough evaluation. ‚
Followup Recommendations
Patients should be given return precautions to the ED for delayed signs of vascular, tracheal, neurologic injury. ‚
Pearls and Pitfalls
- Vascular injuries frequently have delayed presentation.
- Look for vascular injuries in blunt neck trauma patients with neurologic deficit and normal head CT.
- Always prepare for difficult airway and have specialty intervention (anesthesia, ENT) on standby (if available).
Additional Reading
- Miller ‚ PR, Fabian ‚ TC, Bee ‚ TK, et al. Blunt cerebrovascular injuries: Diagnosis and treatment. J Trauma. 2001;51(2):279 " “285.
- Miller ‚ PR, Fabian ‚ TC, Croce ‚ MA, et al. Prospective screening for blunt cerebrovascular injuries: Analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386 " “393.
- Rathlev ‚ NK, Medzon ‚ R, Bracken ‚ ME. Evaluation and management of neck trauma. Emerg Med Clin North Am. 2007;25(3):679 " “694.
- Ullman ‚ E. Blunt neck trauma. In: Wolfson ‚ AB, Hendey ‚ GW, Ling ‚ LJ, et al., eds. Harwood-Nuss ' Clinical Practice of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
Codes
ICD9
- 900.00 Injury to carotid artery, unspecified
- 900.89 Injury to other specified blood vessels of head and neck
- 959.09 Injury of face and neck
- 920 Contusion of face, scalp, and neck except eye(s)
- 807.5 Closed fracture of larynx and trachea
ICD10
- S15.009A Unspecified injury of unspecified carotid artery, initial encounter
- S15.109A Unspecified injury of unspecified vertebral artery, initial encounter
- S19.80XA Other specified injuries of unspecified part of neck, initial encounter
- S10.93XA Contusion of unspecified part of neck, initial encounter
- S12.8XXA Fracture of other parts of neck, initial encounter
- S19.81XA Other specified injuries of larynx, initial encounter
SNOMED
- 58189007 Injury of anterior neck (disorder)
- 6956001 Injury of carotid artery (disorder)
- 262717000 Injury of vertebral artery (disorder)
- 8513005 Contusion of neck (disorder)
- 125588009 Injury of larynx (disorder)
- 262675006 Fractured hyoid bone (disorder)
- 88835002 Closed fracture of thyroid cartilage (disorder)