Neck Trauma

  • Approximately 5-10% of traumatic injuries involve the neck.
  • The most critical and immediately life-threatening problem is airway obstruction and massive hemorrhage.
  • Approximately 3,500 people die each year from neck trauma due to suicides, hangings and accidents.
  • Most blunt trauma is caused by motor vehicle accidents (driver hitting the steering wheel or dashboard) commonly resulting in laryngotracheal injuries.

Critical Landmarks

  • A determination should be made as to whether or not the platysma muscle has been violated. Platysmal violation is often a clue to damage and injury to deeper structures.
  • Zones of the neck (Table 16.3)
  • In order to properly evaluate, diagnose and prioritize neck injuries, the neck is divided into three anatomic zones.
  • Zone I is bounded by the clavicles inferiorly and the cricoids cartilage superiorly and contains many crucial structures including: the lung apices, trachea, aortic arch, the great vessels, esophagus, cervical spine and spinal cord.
  • Injuries in this zone are often difficult to access and repair and carry the highest morbidity and mortality.
  • Zone II is bounded by the cricoids cartilage inferiorly and the angle of the mandible superiorly.
  • Crucial structures in this zone include: the trachea, larynx, esophagus, carotid arteries, jugular veins, vertebral vessels, cervical spine and cord.
  • This zone is easily surgically accessible, and an oblique neck incision can often be used with minimal morbidity.
  • Zone III is bounded by the angle of the mandible inferiorly and the base of the skull superiorly.
    Table Summary—Zones of the neck
    Zones Boundaries Critical Structures Key Points
    III Base of skull
    superiorly
    Angle of
    mandible
    inferiorly    		 trachea, esophagus,
    pharynx, vertebral arteries,
    salivary/parotid glands,
    distal internal carotid
    arteries, jugular veins,
    cranial nerves (9-12)    		 Surgically difficult to access due
    to problems with obtaining
    proper exposure (may
    necessitate disarticulating
    the mandible)
    II Angle of
    mandible
    superiorly
    Cricoid cartilage
    inferiorly    		 trachea, esophagus, larynx,
    jugular veins, common
    carotid arteries (internal
    and external branches),
    vertebral vessels, cervical spine, cervical spinal
    common internal carotid
    cord
  • Low morbidity, best prognosis
  • Easily accessible structures
  • Low threshold for surgical exploration
  • Internal jugular vein and arteries are the most common vascular injuries (9 and 7%, respectively)
    		•
    I Cricoid cartilage
    superiorly
    Clavicles
    inferiorly    		 trachea, esophagus, lung
    apices, aortic arch, great
    vessels, proximal carotid
    arteries, thoracic trauma duct, major cervical nerve
    trunks, vertebral arteries, cervical spine, cervical
    spinal cord
  • Highest morbidity and mortality
  • Injuries difficult to access
    and repair
    		•
  • Structures in this zone include: the trachea, pharynx, esophagus, vertebral arteries, internal carotid arteries and cranial nerves.
  • Injuries in this region are surgically difficult secondary to problems with obtaining proper exposure.

Evaluation of Neck Trauma

  • Early intubation is preferred for proper airway management.
  • An expanding hematoma or laryngeal edema can occur quickly causing airway compromise or occlusion leading to significant morbidity.
  • Neck wounds should NOT be explored in the emergency department due to the risk of dislodging a clot and disrupting hemostasis.
  • In patients with neck trauma, evaluation for arterial injury should be performed. The majority of injuries due to penetrating neck trauma are vascular injuries.
  • The internal jugular vein and common and internal carotid artery are the vessels most frequently injured with frequencies of 9% and 6.7%, respectively.
  • Vertebral artery injury is rare. Typically, this lesion is clinically unsuspected and incidentally identified on angiography. In hemodynamically stable patients, supportive and expectant management is advocated. Definitive treatment is required in patients with persistent bleeding, arteriovenous fistula formation or pseudo aneurysm.
  • Clues to arterial injury include: expanding hematoma, pulsatile bleeding, shock unresponsive to fluids, presence of a new bruit or thrill, diminished distal pulses.
  • Patients with the above findings often require immediate surgical intervention.
  • A high index of suspicion should be maintained for esophageal injury secondary to blunt trauma.

Diagnostic Studies

  • Most patients require a three-view cervical spine series.
  • Plain films can demonstrate subcutaneous emphysema, fractures, tracheal deviation, and foreign bodies (e.g., bullet fragments).
  • A chest X-ray is especially important to evaluate Zone I injuries since this region includes the lung apices. A pneumothorax, hemothorax, subcutaneous emphysema (due to an associated pneumothorax or injury to the larynx, trachea or esophagus), widened mediastinum (due to injury to a major mediastinal vessel) or foreign body may be visualized.
  • Angiography is especially useful in evaluating Zone I and III injuries in hemodynamically stable patients with platysmal violation.
  • The use of color flow doppler is increasing since it is noninvasive and relatively inexpensive. However, this technique is operator dependent and its role in assessing vascular injuries is still unclear.
  • The CT scan is an important tool for diagnosing laryngeal injuries.
  • The role of MRI in penetrating neck injuries is still being evaluated.
  • Endoscopic evaluation of the trachea and/or esophagus should be performed in patients at risk for injuries to these structures. Esophagography (70-80% sensitivity) is important for evaluating esophageal injuries; there is a 17% mortality rate after a 12 h delay in diagnosis of esophageal injuries.

ED Management

  • Hemodynamic stability: Hemodynamically stable patients may undergo a diagnostic evaluation depending on the zone involved (see below) and may not require surgical evaluation. However, hemodynamically unstable patients with neck injuries in any zone require immediate surgical intervention.
  • Zone I: Injuries in this zone are often evaluated using angiography, esophagography or endoscopy (laryngoscopy or bronchoscopy). If the result of any of the above studies is negative the patient is observed and managed medically. If a study result is positive, surgical evaluation should be obtained.
  • Zone II: There are two alternatives for evaluating penetrating Zone II injuries in a hemodynamically stable patient. In the past, any injury with platysmal violation necessitated mandatory surgical intervention. However, this approach is losing favor due to the high negative exploration rate; many centers now favor selective management involving endoscopy, esophagography and angiography as indicated to determine the need for surgical intervention.
  • Zone III: Injuries in this zone are most commonly evaluated by a thorough oropharyngeal examination, as well as laryngoscopy and angiography as indicated.

Strangulation/Hanging

  • Pathophysiology: There are various mechanisms by which death due to hanging or strangulation occurs:
  • Cervical spine fracture and transection of the spinal cord (person drops a large distance with feet not touching the floor)
  • Complete airway and arterial occlusion (compression of crucial structures with loss of consciousness)
  • Cardiac arrest (increased vagal tone and carotid sinus activation)
  • Signs/symptoms: There are many signs and symptoms of strangulation such as ecchymoses, lacerations, abrasions, odynophagia, hoarseness and strider. Petechial hemorrhages, known as Tardieu’s spots, may be present especially on the skin and sub conjunctivae.
  • Diagnosis: Cervical spine injury is rare in no judicial hangings and diagnosis will often be made on the basis of the history or mechanism of injury. A lateral cervical spine film may also demonstrate a Hangman’s fracture (bilateral C2 pedicle fracture with anterior displacement of the C2 vertebral body).
  • Treatment: The main priority of treatment is directed toward maintaining and, if needed, securing the airway. Cervical spine immobilization should be performed when indicated. Cardiopulmonary monitoring should be performed and patients should typically be observed for a minimum of 24 h. Finally, mental health providers should be involved to address the psychiatric component in cases of attempted suicide.

Maxillofacial Trauma

  • Maxillofacial trauma typically occurs as a result of blunt injury to the face with motor vehicle accidents causing 50-70% of maxillofacial fractures.
  • It is important to follow a systematic approach when assessing these patients since traumatic facial injuries can often distract from identifying other potentially life-threatening injuries.
  • Airway management is critical in these patients.
       
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