Neck Trauma

Penetrating traumaBlunt traumaNear - Hanging &

Strangulation

Penetrating Trauma

Symptoms of injuries to structures such as the esophagus can besubtle or delayed in presentation

PathophysiologyMechanism of injury 1. Gunshots ( more dangerous ) 2. Stabbings 3. Miscellaneous

Organ System Classification

Vascular ( most common )PharyngoesophagealLaryngotrachealOthers ( cranial nerve, thoracic duct, brach

ial plexus, spinal cord….

Vascular

Three pathophysiologic mechanisms

External hemorrhageExtending soft tissue hematoma, distort or

obstruct the airwayDisruption of cerebral perfusion ( CVA )

Pharyngoesophageal

Rarely causes any immediate consequenceDelayed diagnosis can lead to serious soft t

issue infection, mediastinitis and sepsis

Laryngotracheal

Small puncture woundAirflow away from respiratory treeObstruction of airway

Wound Location Classification

Anterior (Sternocleidomastoid muscle )PosteriorAnterior

Zone 1 ( below cricoid cartilage ) Zone 2 ( between the cricoid cartilage

and mandible angle ) Zone 3 ( above mandible angle )

Management of Penetrating Trauma

StabilizationCritically injured patient

Rapidly assessing vital functions and the area of injury Performing stabilizing interventions Initiating a diagnostic workup Definitive care

No immediate life threat Violates the platysma ( explore at OR )

* If hemodynamic stability cannot be achieved, prompt transfer to the operating room is in order

Airway

The risk of spinal cord injury is minimalCervical cord injury in a gunshot wound vic

tim when intubation has never been reported

Preintubation radiography is significant

AirwayGeneral Most difficult management dilemma: awake patient with

impending airway obstruction Preoxygenation is important

# Comatous patients & patients in respiratory distress require immediate intubation

# It is controversial whether a stable patient with a nonexpanding hematoma requires intubation in the ED ( close monitor in the ED )

Airway

MethodOral & nasal intubation with or without endosco

pic guidance or muscle relaxantsPercutaneous transtracheal ventilation ( PTV )Surgical airway

Airway

MethodPVT

Airway remains unprotected & uncomfortable in conscious patient

Temporary intervention Complication and contraindication

1. Significant airway obstruction & penetrated airway2. Subcutaneous emphysema, pneumothorax

Airway

MethodSurgical Airway

Last resort ( direct injury to the airway is exception ) cricothyrotomy Tracheostomy or even intubation via the wound

Hemorrhage

External hemorrhageDirect pressureBlindly clamping bleeding vessels is avoidedQuick transfer to the operating roomInter HemorrhageAirway compromisedZone 1 injury result in hemothorax ( thoracosto

my )

Definitive Management of Penetrating Trauma

Unstable patient Immediate transfer to the OR

Stable patient General Mandatory exploration Selective Approach

Definitive Management

Stable PatientGeneral

Lateral neck film CXR ( especially in zone 1 injuries ) NG tube should not be inserted Prophylactic antibiotics

Mandatory explorationSelective Approach

A selective method reserves operative intervention for patients with clinical signs of significant injury

Clinical Findings:Require Surgical Intervention Using a Selective Approach

Expanding or pulsatile hematoma Presence of a bruit Horner syndrome Subcutaneous emphysema Air bubbling through wound Hemoptysis or blood - tinged saliva Shock or active bleeding Absent peripheral pulses Respiratory distressOthers are observed & undergo various diagnostic studies

Other Diagnostic Studies

BronchoscopyEsophagographyEsophagoscopyAngiography

# Patients with Zone 2 wounds who have no clinical manifestation of vascular injury are believed to require no vascular studies

Disposition of Penetrating Neck Trauma

No indication for surgery ==> admission for at least 24 hrs

Blunt Trauma

Rare, compared with penetrating trauma

Motor vehicle crash or an assaultOff - road vehicles

Classification of injuries

Larygotracheal

Pharyngoesophageal

Vascular : delayed dissection or thrombosis ( CVA )

Four recognized mechanisms by which thrombosis can occur

A direct blow to the neckA blow to the head that causes hyperexte

nsion and rotation of the head and lateral neck flexion resulting in a stretch injury to the vessels

Blunt intraoral traumaBasilar skull fracture

Spinal column and spinal cord injuries are moreprevalent in blunt trauma

Clinical Feature

Physical findings may be lacking , it is important to elicit symptoms

1 .Dysphagia, odynophagia2.Voice quality3.Aphonia, muffled voice ( serious injury )

Management of Blunt Neck Trauma

Whether the patient haslaryngotracheal injury?

Definitive ManagementGeneral

C - spine X-ray CXR

Additional Studies Laryngotracheal Vascular Pharyngoesophageal

Additional Studies Laryngotracheal

Plain radiographs CT endoscopy ( fiberoptic bronchoscopy )( Consult chest surgeon or ENT ? )

Vascular Angiography Color Flow Doppler ultrasound

Pharyngoesophageal Threshold for performing diagnostic studies should be low Esophagram & esophagoscope( Consult chest surgeon )

Disposition of Blunt Neck Trauma

Laryngeal injuries do not require immediate repair

Tracheal injuries should receive prompt surgical attention

Near - Hanging & Strangulation

Classification of StrangulationHanging ( most common )Ligature strangulationManual strangulationPostural strangulation

Clinical FeaturesSuperficial & Deep NeckRespiratory (delayed mortality)

Bronchopneumonia Aspiration pneumonitis Delayed airway obstruction ARDS

Neuro psychiatric

Management

Spinal cord injury is very rarePhenytoin: useful in preventing ischemic cer

ebral damageNaloxoneCa2+ channel blocker

Summary

Structured approach to thesepatients, regardless of mechanism is essential to optimize outcome & avoid catastrophe