Neck trauma

Question 1

List the ways in which neck injuries can be divided.

Answer 1

Triangles:

• Posterior triangle - Ant’r border of trapezius, posterior border of SCM and middle 1/3 of clavicle.
• Anterior triangle - Midline, ant’r border of SCM and inf’r mandible.

Zones:

• Zone I: Clavicles to cricoid cartilage
• Zone II: Cricoid to angle of mandible
• Zone III: Angle of mandible to base of skull

Fascial planes:

• Penetrating the platysma
• Not penetrating the platysma

Question 2

List the contents of the anterior neck (Zone 2).

Answer 2

• Carotid and jugular vessels
• Spinal cord
• Recurrent laryngeal nerves
• Vagus and phrenic nerves
• Larynx
• Trachea
• Thyroid cartilage
• Oesophagus
• Thyroid and parathyroid glands
• Submandibular salivary glands

Question 3

What are the hard signs of neck injury?

Answer 3

Vascular:

• Shock despite initial bolus
• Arterial haemorrhage
• Pulsatile or expanding haematoma
• Absent pulse
• Thrill or bruit

Laryngotracheal:

• Stridor
• Haemoptysis
• Objective dysphonia
• Bubbling from wound
• Obstruction

Pharyngo-oesophageal:

Nil

Question 4

What are the soft signs of neck injury?

Answer 4

Vascular:

• Pre-hospital hypotension
• History of arterial bleeding
• Non-pulsatile, non-expanding haematoma
• Proximity wound

Laryngotracheal:

• Hoarseness
• Neck tenderness
• Sub-cut emphysema
• Cervical haematoma or ecchymosis
• Tracheal deviation/disruption
• Laryngeal haematoma or oedema
• Restricted vocal cord mobility

Pharyngo-oesophageal:

• Odynophagia
• Subcut emphysema
• Dysphagia
• Haematemesis
• Blood in mouth
• Saliva from wound
• Prevertebral air
• Trajectory of wound across midline

Question 5

What % pf patients with hard signs of neck injury have an injury requiring surgical intervention?

Answer 5

90%

Question 6

What are the sign’s of Horner’s Syndrome?

What injury can cause it?

Answer 6

Affected side will show:

• Loss of sweating
• Ptsosis
• Miosis

Injury to the sympathetic chain - common to neck injuries in Zones I, II or III - lies on top of carotid/jugular vessels and inside the carotid sheath.

Question 7

What is the criteria system used for determining the need for imaging of Blunt CerebroVascular Injury (BCVI)?

Answer 7

Denver Modification of Screening criteria:

Signs/symptoms:

• Arterial haemorrhage
• Expanding/pulsatile cervical haematoma
• Cervical bruit
• Focal neuro deficit
• Ischaemic stroke on CT
• Neuro findings not accounted for on CT

Risk factors:

• High-energy mech’m w/:
  
  • LeForte 2 or 3
  • Cervical spine #s
    
    • C1-C3 #s
    • Spondylolisthesis/Subluxation of cervical vertebrae
  • Base of skull #s involving the carotid canal
  • DAI w/ GCS < 7
  • Near hanging w/ anoxic brain injury
  • *

Question 8

What system is used to grade BCVI?

Answer 8

The Biffl Classification System

• Grade I: intimal injury w/ <25% stenosis
• Grade II: dissection or intramural haematoma w/ > 25% stenosis
• Grade III: Pseudoaneurysm
• Grade IV: Occlusion of the lumen
• Grade V: Transection with extravasation