Neck Trauma

Author:

Nicholas E. Kman, MD, FACEP

Director, DOC1 EM Clerkship
Associate Professor of Emergency Medicine
The Ohio State University Medical Center
780 Prior Hall
376 West 10th Avenue
Columbus, Ohio 43210

Editor:

Nur-Ain Nadir. MD.

Medical Student Education Director

Simulation Faculty

Assistant Professor

Department of Emergency Medicine

University of Illinois College of Medicine Peoria

Objectives:

Upon finishing this module, the student will be able to:

  1. Describe the approach to blunt neck trauma
  2. Describe the approach to penetrating neck trauma
  3. Describe the approach to Cervical Spine Trauma
  4. Define the role of diagnostic tests in assessing neck trauma

 Introduction

Neck trauma poses a challenge to emergency providers secondary to the important anatomy that occupies a very small amount of real estate.  The airway, vascular system, neurological system, and gastrointestinal tract are all found in this small area and can all be involved in a seemingly innocuous injury.  Additionally, spinal injuries must always be considered in patients with multiple injuries, either blunt or penetrating.

Acute laryngeal trauma is a rare and potentially lethal injury.  It is classified as either blunt or penetrating, according to the mechanism of injury.  Blunt trauma is more common than penetrating trauma.  Motor vehicle collisions (MVCs) are the most common cause of blunt laryngeal trauma and these often occurs in the setting of multi-system trauma.  Gunshot or stab injuries are the most common cause of penetrating laryngeal trauma.

Handling patients with neck trauma is of great importance.  Excessive manipulation and inadequate immobilization of neck injured patients may cause additional neurologic damage and worsen the patient’s outcome.  According to ATLS, at least 5% of patients with spine injury experience the onset of neurologic symptoms or the worsening of preexisting symptoms after reaching the ED.  This chapter will describe neck injuries as they relate to the trauma injured patient.

 Initial Actions and Primary Survey

Assessing a patient for neck trauma begins with the primary survey.  As with all of your patients, your assessment should always begin with addressing airway, breathing and circulation.  Each problem is addressed prior to moving to the next priority (ie, manage airway prior to treating hemorrhage).  Notice that addressing the cervical spine occurs immediately with A (airway) and is also assessed with the neurologic exam that is done as a part of D (disability).

  1. A: Airway Maintenance with CERVICAL SPINE protection- Securing an airway is especially important in suspected laryngotracheal injury. That said, attempts to align the spine for the purpose of immobilization on the backboard are not recommended if they cause pain.
  2. B: Breathing and Ventilation
  3. C: Circulation with hemorrhage control / shock assessment
  4. D: Disability: Neurological status
  5. E: Exposure/Environmental control

Presentation

Describe the classic “textbook” presentation of relevant history and physical. If you can, comment on the sensitivity or specificity of any findings. Make special note of any features that can be used to rule-in (pathognomonic) or rule-out the disease process, if such exist. Also note any variations on the normal presentation.

Cervical Spine and Neck Exam:

  1. Mechanism:
    • Blunt Trauma-may result in crushed larynx, tracheal disruption, expanding hematoma, esophageal leak.
    • Penetrating trauma-may result in injury to major vascular structures, pharynx, larynx, trachea, esophagus
  2. Exam may be misleading as neck trauma may show subtle symptoms and signs prior to obstruction.
  • Obstruction secondary to trauma may be due to direct trauma to larynx or neck
  1. Document the patient’s history and physical examination so as to establish a baseline for any changes in the patient’s neurologic status. [4]
  2. Presentation of inspiratory stridor (supraglottic) or expiratory stridor (subglottic), muffled voice, difficulty handling secretions.
  3. Quick assessment done as part of primary survey in “Disability”. Some important pearls to remember with Cervical

Spine Injuries:

The spinal column consists of cervical, thoracic, and lumbar vertebrae. There are 7 cervical, 12 thoracic, and 5 lumbar vertebrae, as well as the sacrum and the coccyx. The spinal cord contains three important tracts: the corticospinal tract, the spinothalamic tract, and the dorsal columns. 5% of brain injuries have associated C-spine injury

  • 55% spinal injuries are cervical. The cervical spine is the most vulnerable to injury because of its mobility and exposure.
  • 10% of patients with C-spine fractures will have a second noncontiguous vertebral fracture

Spinal cord injury may be categorized by severity as follows:

  1. Incomplete paraplegia (incomplete thoracic injury)
  2. Complete paraplegia (complete thoracic injury)
  3. Incomplete quadriplegia (incomplete cervical injury)
  4. Complete quadriplegia (complete cervical injury)

In order to clear the cervical spine and remove the patient’s collar, they must have the following findings:

  1. Alert, not intoxicated
  2. Absence of neck pain
  3. Absence of midline neck tenderness
  4. Absence of distracting injury
  5. Absence of sensory or motor complaint

Penetrating Neck Trauma Presentation:

  1. Zone III-Above angle of mandible. Angiography
  2. Zone II-Angle of mandible ® Explore, observe, growing role for CTA
  3. Zone I-below cricoid cartilage; Angiography, highest mortality, EGD, esophagoscopy

Blunt Neck Trauma Presentation:

History

  • The majority of blunt laryngeal trauma is due to motor vehicle collisions (MVC) [1]
  • Penetrating laryngeal trauma typically results from gunshot or stab wound
  • Assaults, sports related injuries and clothesline-type injuries are also common
  • Practitioners should ask about the mechanism of the accident, use of restraint or airbag deployment, and associated injuries
  • Symptoms include neck pain, hoarseness, dyspnea, dysphagia, dysphonia, hemoptysis, and respiratory distress [1-3]
  • Any of the 3 primary functions of the larynx — airway, speech, and swallowing — may be involved during a laryngeal injury and should be assessed.

 

Physical

  • Inspiratory stridor (supraglottic) or expiratory stridor (subglottic)
  • Muffled voice
  • Difficulty handling secretions or hemoptysis
  • Ecchymosis
  • Subcutaneous emphysema
  • Absent thyroid prominence
  • Neck or facial crepitus
  • Cartilaginous step off
  • Expanding hematoma
  • Early findings may be subtle

 

Diagnostic Testing

Again make special note of any testing which can be used to rule-in or rule-out the disease process. Include any clinical scoring systems if they exist. (We can build calculators into the site as well).

  1. Lab Tests:
    1. May consider obtaining a trauma panel including CBC, chemistry panel, PT/INR, type and screen and VBG/ABG in the setting of significant injury, but are not diagnostic of laryngotracheal trauma
  2. Neck Trauma Diagnostic Measures:
    1. Larynx – CT is gold standard. CT angiography may be incorporated if vascular injury suspected.
      • Laryngoscopy can be considered. Fiberoptic laryngoscopy: An excellent way to evaluate the supraglottic and glottic larynx; has limitations in evaluating the subglottic area. Examination is best performed with the patient in the upright position to prevent obscuring of the anatomy by the tongue base. [3]
      • Remember that patients initially presenting with a stable-appearing airway may progress to airway obstruction secondary to swelling. Unstable patients or patients with impending airway obstruction should not be sent to the CT scanner [3]
    2. Cervical spine-radiographs, CT. A chest X-ray should be obtained in all circumstances (especially if the platysma has been penetrated). Obtain images as soon as life-threatening injuries are managed. Cervical spine radiography is indicated for all trauma patients who have midline neck pain, tenderness on palpation, neurologic deficits referable to the cervical spine, an altered level of consciousness, or a significant mechanism with a distracting injury or in whom intoxication is suspected. [4]
    3. Esophagus – endoscopy-contrast (water soluble)
    4. Vascular Injury-Angiography if active bleed or pulse deficit; GI blood, hoarseness, subcutaneous air, respiratory distress
      1. Surgical exploration is also a diagnostic option for laryngeal, esophageal and vascular injuries.

Treatment

Describe emergency department treatment options and summarize any further definitive treatment provided by subsequent services.

  1. Neck Trauma Treatment:
    1. General measures: ABCs- Perform primary survey (ABCDEs) and identify and address all life-threats [4]
    2. Securing an airway is essential in suspected laryngotracheal injury
    3. Cervical spine must be secured and immobilized
  2. If the patient is stable, awake flexible fiberoptic examination can be performed; if minimal trauma visualized, oral intubation can be attempted
    1. If attempts at oral intubation fail or are unsafe due to significant trauma, a surgical airway is required; formal tracheotomy is preferred over cricothyrotomy but if patient is unstable, a cricothyrotomy should be attempted [2,3]
    2. Laryngeal mask airways (LMA) are contraindicated, as they can occlude the airway and may also ventilate air through mucosal defects in the larynx to the neck. [3]
  3. Control bleeding with direct pressure-If platysma is violated do not probe
  4. Perform secondary survey (head to toe exam) with a focused neck examination
  5. Foreign bodies should be removed in the operating room
  6. Early consultation is imperative. If surgery is required, the goal should be to conserve all viable structures [5]
  7. Uncontrolled hemorrhage, shock not responding to resuscitation, expanding or pulsatile hematoma, airway compression, and airway communication with wound (as evidenced by bubbling) are all indications for immediate surgical intervention.
  8. Surgical methods vary based on the type of injury. In one review of pediatric patients, Tracheotomy (16 procedures), laryngeal suturing (13 procedures), and laryngeal fracture repair (10 procedures) were the most frequent procedures identified. [6]

Cervical Spine Treatment

  1. Attend to life-threatening injuries first, minimizing movement of the spinal column. Establish and maintain proper immobilization of the patient until vertebral fractures and spinal cord injuries have been excluded. Obtain early consultation with a neurosurgeon and/or orthopedic surgeon whenever a spinal injury is detected. [4]
  2. At present, there is insufficient evidence to support the routine use of steroids in spinal cord injury. [4]

Disposition

  1. All patients with known injury to the laryngotracheal complex should be admitted for observation for at least 24–48 h with serial examination. [3]
  2. Cervical spine injury requires continuous immobilization of the entire patient with a semi-rigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility. [4]

Prognosis

  1. 78% of patients who received early treatment had good voice outcomes [2]
  2. Nearly 90% of all patients had a good result for deglutition
    1. Expedient evaluation, treatment and management often result in favorable outcomes especially with blunt laryngeal trauma

Pearls and Pitfalls

  • A high index of suspicion is need to detect subtle laryngotracheal injuries, especially in the multi-system trauma patient
  • Airway management may be difficult
  • Early detection and treatment leads to good outcomes
  • Cervical spine injuries above C6 can result in partial or total loss of respiratory function.
  • Pitfalls [4]:
  • An inadequate secondary assessment may result in the failure to recognize a spinal cord injury.
  • Patients with a diminished level of consciousness or intoxication are often difficult to assess for the presence of spinal cord injury. These patients require repeat assessment once initial life-threatening injuries have been managed.
  • Patients being transported to a trauma center may have unrecognized spinal injuries and should be maintained in complete spinal immobilization.

 

Figures

Figure 2: Self-inflicted knife laceration to neck.  Patient intubated orotracheally to protect airway.  Used with permission from Dr. Colin Kaide, Ohio State University Department of Emergency Medicine.
Figure 2: Self-inflicted knife laceration to neck. Patient intubated orotracheally to protect airway. Used with permission from Dr. Colin Kaide, Ohio State University Department of Emergency Medicine.
Figure 1: Shotgun pellet wounds diffusely to head and neck.  Patient had penetrating neck wound causing laryngeal injury and airway compromise. Used with permission from Dr. Howard Werman, Ohio State University Department of Emergency Medicine.
Figure 1: Shotgun pellet wounds diffusely to head and neck. Patient had penetrating neck wound causing laryngeal injury and airway compromise. Used with permission from Dr. Howard Werman, Ohio State University Department of Emergency Medicine.
Figure 3: Gunshot wound to the neck with hematoma causing airway compromise.  Patient intubated for airway protection.  Used with permission from Dr. Colin Kaide, Ohio State University Department of Emergency Medicine.
Figure 3: Gunshot wound to the neck with hematoma causing airway compromise. Patient intubated for airway protection. Used with permission from Dr. Colin Kaide, Ohio State University Department of Emergency Medicine.

References

A short list of important articles with the PubMed links / ID.

  1. Lee, WT.; Eliashar, R.; Eliachar, I. “Acute external laryngotracheal trauma: diagnosis and management.” ENT: Ear, Nose & Throat Journal, v. 85 issue 3, 2006, p. 179-84.
  2. Butler, AP.; Wood, BP.; O’Rourke, AK.; Porubsky, ES. “Acute external laryngeal trauma: experience with 112 patients.” Annals of Otology, Rhinology & Laryngology, v. 114 issue 5, 2005, p. 361-8.
  3. Comer, BT.; Gal, TJ. “Recognition and management of the spectrum of acute laryngeal trauma.” Journal of Emergency Medicine, v. 43 issue 5, 2012, p. e289-93.
  4. American College of Surgeons Committee on Trauma. ATLS: 9th edition. Chicago, IL: American College of Surgeons; 2012.
  5. Smith, DF., et al. “Complete traumatic laryngotracheal disruption–a case report and review.” International Journal of Pediatric Otorhinolaryngology, v. 73 issue 12, 2009, p. 1817-20.
  6. Sidell, D.; Mendelsohn, AH.; Shapiro, NL.; St John, M. “Management and outcomes of laryngeal injuries in the pediatric population.” Annals of Otology, Rhinology & Laryngology, v. 120 issue 12, 2011, p. 787-95.
  7. Heidegger, T. “Videos in clinical medicine. Fiber optic intubation.” New England journal of medicine, v. 364 issue 20, 2011, p. e42.
  8. Hsiao, J.; Pacheco-Fowler, V. “Videos in clinical medicine. Cricothyroidotomy.” New England journal of medicine, v. 358 issue 22, 2008, p. e25
  9. Gray, H. Anatomy of the Human Body. Philadelphia: Lea and Febiger; 1918.

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