36. Neck trauma Flashcards
Mortality rate of penetrating neck trauma
10%
Blunt neck trauma - what structures are at risk?
airway
pharyngoesophageal tract
nerves
glandular tissue
blunt cerebrovascular injury to carotid or vertebral artery
Primary concern of blunt neck trauma (ie which structure most worried about) -
blunt cerebrovascular injury to carotid or vertebral artery
Defn of the neck per Rosen’s (where to where, separate by what two cervical fascia)
skull base to T1 VB
superficial and deep/prevertebral cervical fascia
The superficial fascia of the neck lies between the __ and the __ m
skin
platysma
Deep to the platysma muscle is the deep cervical fascia - what are its four layers?
pretracheal
investing
prevertebral layers
carotid sheath
The investing layer runs deep to the platysma and splits which two muscles?
trapezius
scm
prevertebral fascia (deep to investing layer) extends from the neck to thorax and encircles which muscles?
c-spine
prevertebral
The pretracheal fascia completely surrounds which 4 structures?
infrahyoid m
esophagus
trachea
thyroid gland
Why is the pretracheal fascia a particular area of clinical significance?
provides continuity from the neck to the mediastinum - so spillage of neck wounds like from the esophagus can cause mediastinitis
Which layers off deep fascia does the carotid sheath entail?
all 3
What 3 key structures are found in the carotid sheath
internal/common carotid artery
jugular vein
vagus nerve
Neck zones - what are the borders of zone 1
sternal notch to cricoid cartilage
Neck zones - what are the borders of zone 2
cricoid cartilage to the angle of the mandible
Neck zones - what are the borders of zone 3
angle of the mandible to the skull base
What zone is most commonly injured, has the highest mortality, and is most amenable to surgical exploration?
zone 2
What are the borders of the anterior triangle of the neck?
anterior: midline
posterior: scm
superior: lower edge of the mandible
Posterior triangle borders of the neck
anterior: scm
inf: clavicle
posterior: anterior border of trap m
Injury to the anterior vs posterior triangle has a more favorable prognosis?
posterior
Where do the common carotids branch into internal and external carotids?
superior to thyroid cartilage
What type of mechanism causes blunt injury to the carotids?
hyperext-rot mechanism stretching carotid over lateral processes of upper spine, with hyperflexion or direct blow to vessel intraorally or externally
also damage to petrous portion of temporal bone around carotid canal can cause damage
Given the vertebral a runs through the transverse foramina starting at c6, through foramen magnum, what structures may be damaged that could cause risk of ischemic stroke?
tranverse foramina
fracture or facet dislocation of upper c1-c3
stretch and compression around atlantoaxial and atlantooccipital joints
What structures does the larynx contain?
base of tongue to trachea: thyroid, cricoid, epiglottis, paired arytenoid, corniculate, cuneiform cartilages
More than 90% of carotid injuries are caused by __ trauma
penetrating
Which a is more likely to be involved in a penetrating neck injury?
carotid: vertebral a 2:1
Blunt trauma can lead to what 3 vascular concerns of carotid or vertebral a?
occlusion
dissection
intimal flap
What is the most common mechanism for a blunt pharyngoseophageal injury?
falls > mvc
In blunt neck trauma, what laryngotracheal injury is mc?
thyroid cartilage
How does suicide by strangulation lead to death? (pathophys)
external force of ligature causes venous congestion –> leads to unconsciousness with resultant tightening of noose, arterial occlusion and cerebral hypoxia
can also get vagal reflex from pressure on carotid body to lead to fatal dysrhythmia
List 6 hard signs of vascular injury from penetrating neck injury
- severe uncontrolled hemorrhage
- refractory shock/hypotension
- large/expanding/pulsatile hematoma
- unilateral pulse deficit
- bruit/thrill - new or <40y
- neurologic deficit consistent with stroke
Name 3 soft signs for penetrating neck injury vascular injury
minor bleed
small nonexpanding hematoma
proximity wound
Name 4 hard signs of aerodigestive injury of penetrating neck injury
- airway compromise/distress
- air bubbling through wound
- extensive subcutaneous emphysema
- stridor
- hoarse voice
Name 4 soft signs of aerodigestive injury of penetrating neck injury
mild hemoptysis
mild hematemesis
dysphonia
dysphagia
mild subcutaneous emphysema
What is the most concerning complication of BCVI?
stroke
Untreated stroke risk following BCVI is _% in 7d
10-40
What are the two screening criteria sets for BCVI?
modified denver
modified memphis
List 5 signs/sx of BCVI from the modified Denver critieria
- Arterial hemorrhage from neck, nose, or mouth
- Cervical bruit (in patients <50 years)
- Expanding cervical hematoma
- Focal neurologic deficit: TIA, Horner syndrome,
vertebrobasilar symptoms, hemiparesis - Stroke findings at CT or MRI
- Neurologic deficit inconsistent with head CT
findings
List 6 RFof BCVI from the modified Denver critieria
- LeFort II or III fracture
- Basilar skull fracture involving the carotid canal
- Cervical vertebral body or transverse foramen
fracture - Cervical subluxation, or ligamentous injury at any
level - Fracture at C1–C3
- Closed head injury consistent with DAI and GCS
score <6 - Near-hanging with anoxia
- Clothesline-type injury or seat belt abrasion with
significant swelling, pain, or altered mental status
Name 6 Modified Memphis criteria for screening for BCVI
- Basilar skull fracture with involvement of the carotid canal
- Basilar skull fracture with involvement of petrous bone
- Cervical spine fracture
- Neurologic examination not explained by brain
imaging - Horner syndrome
- LeFort II or III fracture pattern
- Neck soft tissue injury (seatbelt sign or hanging or
hematoma)
What are 5 injury types that are associated with BCVI in CHILDREN?
basilar skull fracture
cervical spine injury
injury severity score >/=16
brain infarct
hanging
Le Fort fracture
facial fracture
clavicle fracture
List 6 symptoms of penetrating laryngotracheal injury
dyspnea
dysphonia
dysphagia
hoarse
laryngeal pain and tenderness
stridor
hemoptysis
subcut emphysema
cyanosis
air from the wound
sign air leak or persistent PTX following chest tube placemement
Are blunt or penetrating laryngotracheal injuries more concerning per rosens?
blunt
??
Name 6 signs of blunt LT injury
subcutaneous emphysema, air escape, external bleeding or bruising, dyspnea, hypopnea, stridor, cough, pain with phonation, dysphagia, hemoptysis, tracheal devia- tion, cyanosis, and nerve injury. Associated cervical spine injury occurs in up to half of patients.42 Evaluation for hoarseness due to recurrent laryngeal nerve injury should be considered when a cricoid cartilage fracture is found because of proximity.29
How does pulmonary edema potentially occur from hypoxic-ischemic brain injury in hanging?
central mediated neurogenic pulmonary eema with massive sympathetic discharge
post-obstructive from marked negative intrapleural pressure by forceful inspiratory effort against extrathoracic obstruction
cardiogenic pulmonary edema - likely secondary to takutsubo from hanging stress
What are the punctate lesions left by gravitational pressure causing capillary rupture on the neck after hanging known as?
Tardieu spots
Penetrating blunt neck trauma - if stable enough, what imaging/testing?
ct/cta
efast
hbg
t+s + crossmatch
coag function
plt
What old school method was used to look for vascular injury?
digital subtraction angiography/DSA
Name 3 mechanisms for penetrating neck injury causing carotid/vertebral a injury/LT or pharyngoesophageal injury
stab wound
fire arm
bite, glass, other
Name 8 signs or symptoms for penetrating neck injury causing carotid/vertebral a injury
Asymptomatic, minor bleeding, small, nonexpanding hematoma, proximity wound, severe, uncontrolled hem- orrhage, refractory shock or hypotension, large or expanding or pulsatile hematoma, unilateral pulse deficit, bruit or thrill, neurologic deficit consistent with stroke.
Name 4 signs or symptoms sp to vertebral a injury for penetrating neck injury
Vertebral artery specific: dizziness, vertigo, diminished coordination, disequilibrium, ataxia, nausea and/or vomiting, neck or head pain, altered sensorium, speech (dysarthria), visual deficits (double vision, nystagmus), lower cranial nerve palsies and medial or lateral medullary syndrome
Name 8 signs or symptoms for penetrating neck injury causing LT injury
Asymptomatic, respiratory distress, dyspnea, dysphonia, aphonia, dysphagia, hoarseness, pain or tenderness over larynx, stridor, hemoptysis, subcutaneous emphysema, cyanosis, air escaping from wound, irritating cough
Name 8 signs or symptoms for penetrating neck injury causing pharyngoesophageal injury
Asymptomatic, air leaking from the wound site, odynophagia, dysphagia, hematemesis, subcutaneous emphy- sema, and blood in the saliva or nasogastric tube aspirate, dyspnea, hoarseness, stridor, cough, pain and tenderness in the neck, and resistance to passive neck movement
Carotid a injury in blunt mechanism: what is a salient RF
lefort # II or III
carotid canal injury
Carotid a injury in blunt mechanism: what is a salient mechanism
mvc
Carotid a injury in blunt mechanism: what is a salient sign/sx
asx
neuro findings
hroner syndrome
bruit
expanding hematoma
Vertebral a injury in blunt mechanism: what is a salient RF
c spine injury to 1-3 or dislocation, any transverse foramina
Vertebral a injury in blunt mechanism: what is a salient mechanism
mvc
Vertebral a injury in blunt mechanism: what is a salient sign/sx
asx
neurologic findings
LT injury in blunt mechanism: what is a salient mechanism?
direct trauma
LT injury in blunt mechanism: what is a salient RF
assoc cspine injury
LT injury in blunt mechanism: what is a salient sign/sx
Asymptomatic, subcutaneous emphysema, air escape, external bleeding or bruising, dyspnea, hypopnea, stridor, wheezing, cough, pain with phonation, dysphagia, hemoptysis, tracheal deviation, cyanosis, nerve injury
Pharyngoesophageal injury in blunt mechanism: what is a salient mechanism (3)
fall
mvc
strangulation
Pharyngoesophageal injury in blunt mechanism: what is a salient RF
facial fracture
tbi
Pharyngoesophageal injury in blunt mechanism: what is a salient sign/sx
exttrapolated from penetrating trauma
Thyroid gland hematoma in blunt mechanism: what is a salient mechanism
anterior neck trauma
Thyroid gland hematoma in blunt mechanism: what is a salient RF
goiter
Thyroid gland hematoma in blunt mechanism: what is a salient sx
painful swelling
dyspnea
airway obstruction
Nerve injury in blunt mechanism: what is a salient mechanism?
bone fragment in facial canal
Nerve injury in blunt mechanism: what is a salient RF
temporal bone fracture
Nerve injury in blunt mechanism: what is a salient sign/sx
facial paralysis
What is the best imaging study to visualize esophagus if concerned for phayngoesophageal injury?
esophageal barium swallow/contrast swallow study or esophagogram
Morbidity of delayed penetrating pharyngoesophageal injury - 4 examples?
sepsis
emphysema
perc feeding
trach tubes
How to manage a penetrating neck injury with vascular injury
- Direct pressure
- foley cath 16-18 french foley cath and inflate in wound - likely to help in zone 3
- probably surgery if this bag - primary repair/endovascular stent grafting
What is the Biffl scale grading and treatment for?
BCVI
Biffl scale grade 1 injury and management
Intimal injury or irregular intima
anticoag or antiplt therapy (endovascular repair if not candidate)
Biffl scale grade 2 injury and management
dissection with intimal flap causing luminal narrowing of <25%
endovascular repair if sx or if w/o then antiplt/anticoag
Biffl scale grade 3 injury and management
Pseudoaneurysm formation
Endovascular repair if symptoms; other- wise antiplatelet or anticoagulant
Biffl scale grade 4 injury and management
Vessel occlusion or thrombosis
Difficult to manage, as the injured vessel often thromboses and cannot be recanalized, endovascular repair if sx; o/w antiplatelet or anticoagulant
Biffl scale grade 5 injury and management
Vessel transection
Typically, lethal if left untreated; requires immediate endovascular intervention or surgical repair
Medical management of BCVI
Antithrombotic therapy is indi- cated in all grade I to IV injuries. For anticoagulation, the standard regimen includes a heparin infusion started at 10 units/kg/h and titrated to a PTT of 40 to 50 seconds. No heparin bolus is adminis- tered. If antiplatelet therapy is selected, 75 to 325 mg/day of aspirin (or 3 to 5 mg/kg in children) is recommended with some studies showing fewer bleeding-relate.
3-6mo
How much does antocoag or antiplt decreaes stroke risk for BCVI
1-7%
Surgical management options of BCVI
stenting
vessel sacrifice
If suspect esophageal injury, what abx and tx?
piptazo IV or flconazole IV for anaerobic coverage
NPO
NG
When is an esophageal injury from penetrating trauma able to be nonop?
HD stable
no competing indications for exploration
no established sepsis
reinforced if waer soluble swallow study shows contained extravasatation or none
When should esophageal injuries go for surgery?
uncontained perf
signs of sepsis
widespread contamination
What percent of blunt pharyngoesophageal injury patients require surgery?
1/4
Recommendations for approaching laryngotracheal injuries with airway compromise
- orotrach ETT trial if emergent
one size smaller than expected given airway edema
- doublet set up for crich - semi elective: fiber optic intubatio/awake trach in OR
DO NOT NASAL TRACHEAL INTUBATE
What is the grading system of injury for definitive management of LT trauma ?
Schaefer-Fuhrman
Schaefer-Fuhrman grade 1 injuries and management
Endolaryngeal hematoma or laceration without detectable fracture; no airway compromise
Generally, medically managed and do not require surgical intervention. Helpful adjunctive medical treatments include steroids, antibiotics, humidification, voice rest
Schaefer-Fuhrman grade 2 injuries and management
Moderately severe edema, hematoma, or lacera- tion without exposed cartilage or nondisplaced fracture; partial airway compromise with varying degrees of severity
Serial examinations, since the injuries may worsen over time. These injuries infrequently require a tracheostomy. Helpful adjunctive medical treatments as described above
Schaefer-Fuhrman grade 3 injuries and management
Massive laryngeal edema, large mucosal lacera- tions, exposed cartilage, displaced fracture, or vocal cord immobility, with associated airway compromise
Tracheostomy and surgical repair are often required. The following injuries of the larynx require surgical repair: disruption of the anterior commissure, major endolaryngeal lacerations, vocal cord tear, immobile vocal cord, cartilage exposure, displaced cartilage fractures
Schaefer-Fuhrman grade 4 injuries and management
Grade III findings with more severe anterior laryngeal disruption, unstable fracture, two or more fracture lines, or severe mucosal injuries
Tracheostomy is always required
Surgical repair requires stent placement to maintain the integrity of the larynx
Schaefer-Fuhrman grade 5 injuries and management
Complete laryngotracheal separation
Disruption of the airway usually occurs above or below the cricoid cartilage, either at the cricothy- roid membrane or cricotracheal junction. The airway is usually temporarily established using an endotracheal tube inserted through the neck directly into trachea distal to the site of transec- tion. A complex laryngotracheal repair is then performed through a low cervical incision
dispo: penetrating wound in an asymptomatic or minimally symptomatic patient with no evidence of a viscerovascular injury and a negative CTA ??
serial examinations every 6 to 8 hours for 24 to 36 hours are recommended
BCVI - admission?
yes even grade 1 can progres to grade 3 in short time period - if no image but high risk monitor 24-48h
BCVI recommendations for activity
avoid contact sport
neck manipulation
e2 containing meds
htn
BCVI repeat cta
within 7d to confirm dx, if not seen can stop therapy
at 3mo for resolution
Hanging - when are they medically cleared?
no injury
no pulmonary edema after several hours of observation
The presence of which of the following signs after penetrating neck trauma would indicate a likely benefit from surgical intervention? a. Decreased or absent radial pulse
b. Small degree of hemoptysis
c. Horner syndrome d. Muffled voice
e. Stable hematoma
a
Which of the following is true regarding pharyngoesophageal inju- ries?
a. Esophageal barium swallow is the best initial x-ray modality for evaluating esophageal injuries.
b. Gastrografin has greater sensitivity than barium and is therefore the preferred contrast agent in the initial evaluation of esopha- geal injuries.
c. Confirmatory barium study is not necessary after a negative Gastrografin swallow study.
d. Computed tomography angiogram (CTA) is the initial study of choice in evaluating pharyngoesophageal injuries and never requires additional confirmatory studies
e. None of the above is true.
e
The pathophysiology and sequelae of hanging include all of the fol- lowing except
a. Pulmonary edema
b. Hypoxic –ischemic brain injury
c. Cardiogenic pulmonary edema as a result of Takotsubo cardio- myopathy
d. Neurogenic pulmonary edema from massive parasympathetic discharge
e. Presence of Tardieu spots
d - “sympathetic”
Which of the following statements is true regarding zonal injuries
to the neck?
a. Zone 2 is the most commonly injured, has the highest mortality
and is most amenable to surgical exploration
b. Zone 1 extends from the sternal notch to the cricoid cartilagec. Penetrating trauma injuries to the neck often span multiple zones, and the most significant injury may lie in a different zone than the point of entry
d. Current consensus supports a “no-zone” approach which uses clinical examination coupled with computed tomography angio- gram (CTA) to arrive at the best diagnostic and therapeutic pathways
e. All of the above are true.
e
- Which of the following statements regarding airway management
after penetrating neck trauma is true?
a. Awake fiberoptic intubation is the first-line technique.
b. Bag-valve-mask ventilation should be high tidal volume, low
c. Cervical spine immobilization is typically unnecessary.
d. Nasotracheal intubation is relatively contraindicated in neck
trauma.
e. Preintubation nasogastric tube (NGT) placement may be lifesav-
ing.
c
