Monday, February 6, 2023

Neck Trauma

Practice Essentials

With the neck protected by the spine posteriorly, the head superiorly, and the chest inferiorly, the anterior (larynx and trachea) and lateral regions are most exposed to trauma.
 Few emergencies pose as great a challenge as neck trauma. Because a multitude of organ systems (eg, airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound is capable of considerable harm. Furthermore, seemingly innocuous wounds may not manifest clear signs or symptoms, and potentially lethal injuries could be easily overlooked or discounted.

Neck injury may result in the laceration of major vessels, potentially leading to hemorrhagic shock. Extracranial arterial injuries to the brachiocephalic, common carotid, and vertebral arteries can result in major neurologic deficits.

Airway occlusion and exsanguinating hemorrhage pose the most immediate risks to life. From the time when Ambroise Pare successfully treated a neck injury in 1552, debate has continued about the best approach for particular neck wounds. Awareness of the various presentations of neck injuries and the establishment of a well-conceived multidisciplinary plan prior to the traumatic event is critical for improving patient outcome.

The neck is divided into anatomic zones or regions to assist in the evaluation of neck injuries. The image below illustrates the zones of the neck.

Neck trauma. Zones of the neck.

Neck trauma. Zones of the neck.

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Signs and symptoms

Signs of laryngeal or tracheal injury

Voice alteration

Hemoptysis

Stridor

Drooling

Sucking, hissing, or air frothing or bubbling through the neck wound

Subcutaneous emphysema and/or crepitus

Hoarseness

Dyspnea

Distortion of the normal anatomic appearance

Pain on palpation or with coughing or swallowing

Pain with tongue movement

Crepitus: Noteworthy in only one third of cases

Signs of esophageal and pharyngeal injury

Dysphagia

Bloody saliva

Sucking neck wound

Bloody nasogastric aspirate

Pain and tenderness in the neck

Resistance of neck with passive motion testing

Crepitus

Bleeding from the mouth or nasogastric tube

Signs of carotid artery injury

Decreased level of consciousness

Contralateral hemiparesis

Hemorrhage

Hematoma

Dyspnea secondary to compression of the trachea

Thrill

Bruit

Pulse deficit

Signs of jugular vein injury

These include hematoma, external hemorrhage, and hypotension.

Signs of spinal cord or brachial plexus injury

Diminished upper arm capacity

Quadriplegia

Pathologic reflexes

Brown-Séquard syndrome

Priapism and loss of the bulbocavernous reflex

Poor rectal tone

Urinary retention, fecal incontinence, and paralytic ileus

Horner syndrome

Neurogenic shock

Hypoxia and hypoventilation

Signs of cranial nerve injury

Facial nerve (cranial nerve VII): Drooping of the corner of the mouth

Glossopharyngeal nerve (cranial nerve IX): Dysphagia (altered gag reflex)

Vagus nerve (cranial nerve X, recurrent laryngeal): Hoarseness (weak voice)

Spinal accessory nerve (cranial nerve XI): Inability to shrug a shoulder and to laterally rotate the chin to the opposite shoulder

Hypoglossal nerve (cranial nerve XII): Deviation of the tongue with protrusion

See Clinical Presentation for more detail.

Diagnosis

Imaging studies

In addition to cervical and chest radiography, the following supplementary tests may be useful:

Computed tomography (CT) scanning

Magnetic resonance imaging (MRI)

Color flow Doppler ultrasonography

Contrast studies of the esophagus

Interventional angiography

Endoscopy

Laryngoscopy, bronchoscopy, pharyngoscopy, and esophagoscopy may be useful in the assessment of the aerodigestive tract. Rigid endoscopes are superior to flexible scopes.

See Workup for more detail.

Management

In neck trauma, emergency department care commences with assessment and stabilization of the patient’s airway, breathing, and circulation (ABCs):

Airway: Perform emergent orotracheal intubation in patients displaying signs of acute or impending respiratory distress

Breathing: Ventilatory distress that persists beyond competent intubation indicates a possible tension pneumothorax, which requires needle decompression and chest tube placement

Circulation: Bleeding that originates from neck trauma is controlled with direct pressure; in selected cases, bleeding that cannot be controlled or reached with direct pressure may benefit from balloon tamponade

In rare instances, when applying direct pressure to wounds is impractical, a cricothyroidotomy may be required, with subsequent packing of the pharynx as a temporary strategy.

See Treatment and Medication for more detail.

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