Evaluation and Management of Blunt Neck Trauma

Motor vehicle collision (MVC)

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  Most common cause

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  Injuries may result from:

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    steering wheel.

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    dashboard.

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    shearing force from shoulder belt.

Hanging leading to neck strangulation

Punching in the neck

Chiropractic excessive manipulation leading to carotid or vertebral arterial injury

Laryngotracheal injury

Cervical spine injury with or without spinal cord injury (SCI)

Pharyngoesophageal injury

Blunt cerebrovascular injury

Brachial plexus injury

Apex of the lung injury

Assessment of the airway

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  Definitive airway for respiratory distress

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  Causes of respiratory distress

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    Tracheal injury

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    Laryngeal injury

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    Neck hematoma

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    Tracheal or laryngeal edema

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  Surgical airway: tracheostomy

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    If suspected or confirmed airway injury

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  Nonsurgical airway: Endotracheal (ET) intubation

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    If no concern of airway injury

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    Laryngeal injury where trachea or larynx is tenuously attached can result in complete loss of the airway if the larynx detaches and dislodges into the chest during ET intubation.

Protection of the C-spine

Assessment for impaired breathing

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  Impaired breathing in blunt neck trauma may be due to:

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    associated hemothorax or pneumothorax in Zone I neck injury.

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    tracheobronchial obstruction from foreign body.

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    pulmonary edema in patients with strangulation.

Assessment of the circulation

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  Hemodynamic instability

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  Hard signs of vascular injury

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    Carotid bruit

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    Expanding/pulsating hematoma

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    Absent pulse

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    Neurological deficit

Assessment for neurological deficit

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  Associated cervical spine injury may cause SCI or brachial plexus injury leading to neurological deficit.

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  Blunt cerebrovascular injury may result in cerebral ischemia leading to neurological deficit.

Laryngeal or tracheal injury

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  Hoarseness of voice

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  Pain on palpation or with coughing or swallowing

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  Dyspnea

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  Hemoptysis

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  Stridor

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  Subcutaneous emphysema and/or crepitus

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  Distortion of the normal anatomic appearance

Tracheobronchial or apical pleural or lung injury

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  Respiratory distress

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  Hoarseness or dysphonia

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  Subcutaneous emphysema

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  Respiratory distress

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  Hemoptysis

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  Tension pneumothorax

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    Decreased breath sounds

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    Hyperresonance to percussion

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    Hypotension

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    Hypoxia

Carotid artery injury

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  Decreased level of consciousness

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  Contralateral hemiparesis

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  Pulsatile neck hematoma

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  Dyspnea secondary to compression of the trachea

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  Bruit

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  Pulse deficit

Jugular vein injury

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  Hematoma

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  Hypotension

Esophageal and pharyngeal injury

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  Dysphagia

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  Blood in saliva

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  Blood in nasogastric aspirate

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  Pain and tenderness in the neck

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  Crepitus

Chest X -ray may reveal:

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  cervical emphysema.

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  pneumothorax.

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  pneumomediastinum.

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  hemothorax.

Computerized tomography (CT) of the neck for evaluation of:

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  Cervical spine injury

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  Airway injury

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  Findings suggestive of laryngotracheal injury

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    Cervical emphysema

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    Separation in the tracheobronchial air column

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    Displacement of trachea

CT of the chest

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  Zone I injury may demonstrate:

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    hemothorax.

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    pneumothorax.

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    widened mediastinum.

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    mediastinal emphysema.

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    apical pleural hematoma.

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    great vessel injuries.

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    mediastinal hematoma.

CT angiography: Chest

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  Evaluation of aortic injury in Zone I blunt trauma

CT angiography of the neck:

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  Evaluation of the suspected cervical vascular injury or for the screening of cervical vascular injury if indicated.

Contrast esophagogram

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  Evaluation of cervical esophageal injury

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  Water-soluble iodinated contrast should be used for preliminary detection of perforation.

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  Barium-contrast esophagogram is recommended if high index of suspicion for injury with negative water-soluble contrast esophagogram.

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  Nontransmural esophageal injuries are not detected on an esophagogram.

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  Does not rule out a pharyngoesophageal leak

Bronchoscopy

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  For definitive diagnosis of suspected airway injury

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  Fiberoptic bronchoscopy can be used even in patients with cervical spine injuries.

Laryngoscopy

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  Provides information about the location and extent of injury

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  Rigid endoscopes are superior to flexible scopes.

Esophagoscopy

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  Role of esophagoscopy in blunt injury is inconclusive.

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  It is contraindicated in patients with small mucosal or submucosal tears seen in CT scan or esophagogram. It may exacerbate the injury or cause perforation.

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  It may be performed in patients with high index of suspicion of injury despite negative CT scans and esophagograms.

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  It is not indicated as the initial diagnostic tool.

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  Flexible endoscopy and contrast esophagography are complementary and together give the highest diagnostic yield.

Low incidence of tracheal injury after a blunt trauma compared to penetrating trauma

Most blunt trauma involves the distal intrathoracic trachea and right mainstem bronchus.

Mechanism of injury

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  Direct neck trauma causing impact against the vertebral bodies

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  MVC with sudden hyperextension injury

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    Neck hitting the steering wheel or dashboard

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    Traction and distraction injury causing laryngotracheal separation

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    Seat belt injury causing compressive and rotational impact to the neck