Neck Trauma Flashcards
How many zones are there in relation to penetrating neck trauma?
Three
What are the boundaries and contents of zone 1 in relation to penetrating neck trauma?
Zone 1
Clavicles to carotid
Contains great vessels, trachea, esophagus, lung apex
What are the boundaries and contents of zone 2 in relation to penetrating neck trauma?
Zone 2
Carotid to mandible angle
Contains carotid, jugular, vagus nerve, phrenic nerve, larynx, esophagus, trachea
What are the boundaries and contents of zone 3 in relation to penetrating neck trauma?
Zone 3
Mandible angle to skull base
Contains proximal carotids, jugular vein, vertebral artery, oropharynx, c-spine
What are the hard signs of vascular injury in neck trauma?
- Severe hemorrhage
- Expanding hematomas
- Hemodynamic instability
- Bruit/thrill over injury
- Absent/diminished pulse
- Stroke symptoms
A 67-year-old woman is evaluated in the intensive care unit for neck swelling. An hour ago, the patient was admitted to the ICU for treatment of pyelonephritis complicated by septic shock and disseminated intravascular coagulation. A central line catheter was placed in the right internal jugular vein. The insertion was difficult, requiring multiple attempts. X-ray after placement revealed the catheter to be in a good position. Over the past 30 minutes, she has developed swelling at the site of the catheter and a feeling of tightness in her neck. She also feels her voice is changing. On examination, there is ballotable swelling under the site of the catheter with surrounding ecchymosis, and the trachea is deviating to the left. The voice sounds hoarse. What is the most appropriate next step in management of this patient?
This coagulopathic patient with an enlarging fluid collection after difficult intravenous cannulation has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction from direct mechanical airway compression collapsing the structural support of the airway and causing narrowing of the lumen and compression of the lymphovasculature, leading to impaired venous drainage, which causes vascular congestion and intrinsic laryngeal mucosal edema that narrows the airway lumen. Signs of airway obstruction can include tracheal deviation and hoarseness (as seen in this patient); other clinical features include stridor, dysphagia, voice changes, and
tripod positioning. However, patients can initially have few or no symptoms, including a normal peripheral blood oxygenation concentration, until rapid (<min) decompensation. Although some expanding neck hematomas (eg, post-surgical) should be evacuated immediately, in this patient with a severe coagulopathy and possible damage to great vessels, it is more appropriate to adequately secure the airway, typically via oral endotracheal intubation. Ideally, a surgical airway should be avoided due to the increased risk of bleeding, but it may become unavoidable if the larynx cannot be visualized for intubation. Removing the catheter may worsen the hematoma because the catheter may be tamponading some of the blood flow. In addition, removal would not protect the airway, and its presence still may be needed to deliver resuscitative fluids and treatment medications.
What are the hard signs of airway or esophageal injury in neck trauma?
- Hemoptysis
- Hematemesis
- Respiratory distress/failure
- Air bubbling from wound
- Subcutaneous emphysema
What is the preferred initial imaging modality for stable patients with penetrating neck trauma?
CTA (Computed Tomography Angiography) is preferred for stable patients.
What is the management for unstable patients with penetrating neck trauma?
Immediate endotracheal intubation for airway compromise, emergent surgical intervention for hemodynamic instability, expanding hematoma, or hard signs of esophageal, tracheal, or vascular injury.
What should be done if no injury is found on CTA for penetrating neck trauma?
Conservative monitoring with close observation if no injuries are demonstrated.
What is the pathology behind carotid artery dissection from chiropractor manipulation?
Chiropractic neck manipulation can cause intimal tears in the carotid artery, leading to thrombus formation and embolism, resulting in ischemic stroke or transient ischemic attacks (TIAs).
How do you diagnose carotid artery dissection?
CTA or MRI/MRA showing an intimal flap, tapering occlusion, or mural thrombus in the carotid artery.
What is the management of carotid artery dissection?
Anticoagulation (heparin → warfarin) or antiplatelet therapy (aspirin, clopidogrel) to prevent embolism. Endovascular stenting if severe occlusion or persistent symptoms.
What is the initial approach for suspected cervical spine injury in neck trauma?
Immobilization of the cervical spine (C-spine) with a cervical collar until injury is ruled out via imaging (CT C-spine).
What are the indications for CT C-spine in neck trauma?
High-risk criteria: Neurologic deficits, midline cervical tenderness, distracting injury, altered mental status (NEXUS criteria).
What is the management for a C-spine injury with neurological deficits?
High-dose IV corticosteroids (controversial), neurosurgical consultation, possible spinal decompression surgery.
What is subcutaneous emphysema in neck trauma and what does it indicate?
Palpable air under the skin (crepitus) indicating esophageal or tracheal injury.
What is the best test to diagnose esophageal injury in neck trauma?
Esophagram with water-soluble contrast, followed by barium swallow or endoscopy if needed.
What are the signs of vertebral artery dissection in neck trauma?
Horner syndrome (ptosis, miosis, anhidrosis), posterior circulation stroke symptoms (vertigo, ataxia, dysphagia), headache, and neck pain.
How do you diagnose vertebral artery dissection?
MRI/MRA of the head and neck showing an intimal flap or occlusion of the vertebral artery.
What is the treatment for vertebral artery dissection?
Anticoagulation (heparin to warfarin) or antiplatelets (aspirin, clopidogrel) to prevent thromboembolism.
What is the management of an expanding neck hematoma?
Airway management with endotracheal intubation and emergent surgical exploration.
How do you manage a patient with a laryngeal fracture from neck trauma?
Airway management (endotracheal intubation or tracheostomy if needed), CT scan to assess severity, and possible surgical repair.
