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Neck Trauma, Blunt, Anterior, Emergency Medicine

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

- 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)

- 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

  • Blunt anterior neck trauma may result in various injuries to structures in the neck:Vascular:Carotid artery injury (internal, external, common carotid)Vertebral artery injuryIntramural hematoma, intimal tear, thrombosis, and pseudoaneurysmHemorrhage or neck hematomaLaryngotracheal:Laryngeal injuries: Fracture of hyoid bone, thyroid cartilage, cricoid cartilage, cricotracheal separationVocal cord disruptionDislocation of arytenoid cartilageTracheal injuries: Hematoma or transectionPharyngoesophageal:Pharynx: Hematoma, perforationEsophagus: Hematoma, perforationNervous system:Thoracic sympathetic chain wraps around carotid artery: Disruption can result in Horners syndromeVagus nerve and recurrent laryngeal nerveCervical nerve roots and spinal cordCervical 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, edemaCarotid bruit or thrill (pathognomic for vascular injury)Neurologic deficits (often delayed)Laryngotracheal injury:Voice changes, hoarseness, aphoniaDyspnea, inspiratory stridor, labored breathing, "air hunger " ¯SC emphysema, tenderness to palpationPharyngoesophageal injury (rarely isolated):Dysphagia, odynophagia, hematemesis, blood in salivaTenderness to palpationInfection, 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 injury4-vessel angiography is considered gold standard for evaluation of arterial injury.
  • Indications for angiography:Presence of carotid bruitExpanding neck hematomaNeurologic deficit without intracranial pathology on CTHorners syndromeDecreased 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:OdynophagiaHematemesis or blood in salivaSC 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:StridorAir hungerLabored breathingExpanding 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 outcomesRequires 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 orClindamycin: 600 " “900 mg (peds: 25 " “40 mg/kg/d div. q6 " “8h) IV q8h orPenicillin G: 2.4 million U/d (peds: 150,000 " “250,000 U/kg/d) IV q4 " “6h, + metronidazoleMetronidazole: 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)