Trauma To The Neck

Question 1

True or false

Wounds that do not penetrate the platysma are not life threatening.

Answer 1

True

Question 2

Which zone undergoes surgical exploration?

Answer 2

Zone 2

(2urgical exploration)

Question 3

Which zone wounds undergo further evaluation?

Answer 3

Zone 1 and 3

(1urther 3valuation)

Question 4

Anatomic Boundaries of Zone 1

Answer 4

Clavicles to the cricoid cartilage

Question 5

Anatomic Boundaries of Zone 2

Answer 5

Cricoid cartilage to the angle of the mandible

Question 6

Anatomic Boundaries of Zone 3

Answer 6

Angle of the mandible and the base of the skull

Question 7

Zone 1 Structures

Answer 7

Proximal carotid vertebral arteries
Major thoracic vessels
Superior mediastinum
Lungs
Esophagus
Trachea
Thoracic duct
Spinal cord

(PMS-LETTS)

Question 8

Zone 2 Structures

Answer 8

Carotid and vertebral arteries
Jugular veins
Esophagus
Trachea
Larynx
Spinal cord

(CJ-LETS)

Question 9

Zone 3 Structures

Answer 9

Distal carotid and vertebral arteries
Pharynx
Spinal cord

(DPS)

Question 10

Clinical Factors Indicating Need for Aggressive Airway Management

Answer 10

• Stridor
• Acute respiratory distress
• Airway obstruction from blood or secretions
• Expanding neck hematoma
• Profound shock
• Extensive subcutaneous emphysema
• Alteration in mental status
• Tracheal shift

Question 11

Relative Indications for Airway Management

Answer 11

• Progressive neck swelling
• Voice changes
• Progressive symptoms
• Massive subcutaneous emphysema of the neck
• Tracheal shift
• Alteration in mental status
• Expanding neck hematoma
• Need to transfer symptomatic patient
• Symptomatic patient with anticipated prolonged time away from ED

Question 12

Pathologic Findings on Conventional Radiographs

Soft tissue neck radiograph

Answer 12

• Prevertebral air
• Foreign body or bullet fragments
• Tracheal narrowing or deviation
• Subcutaneous or retropharyngeal emphysema

Question 13

HARD
Signs and Symptoms of Neck Injury

Laryngotracheal injury

Answer 13

Stridor
Hemoptysis
Dysphonia
Air or bubbling in wound
Airway obstruction

(DAHAS)

Question 14

HARD
Signs and Symptoms
Vascular injury

Answer 14

Shock unresponsive to initial fluid therapy
Active arterial bleeding
Pulse deficit
Pulsatile or expanding hematoma
Thrill or bruit

(SAPAT)

Question 15

SOFT Signs and Symptoms

Answer 15

Hypotension in field
History of arterial bleeding
Nonpulsatile or nonexpanding hematoma
Proximity wounds

Question 16

SOFT
Signs and Symptoms Laryngotracheal injury

Answer 16

Hoarseness
Neck tenderness
Subcutaneous emphysema
Cervical ecchymosis or hematoma
Tracheal deviation or cartilaginous step-off
Laryngeal edema or hematoma
Restricted vocal cord mobility

Question 17

SOFT Signs and symptoms

Pharyngoesophageal injury

Answer 17

Odynophagia
Subcutaneous emphysema
Dysphagia
Hematemesis
Blood in the mouth
Saliva draining from wound
Severe neck tenderness
Prevertebral air
Transmidline trajectory

Question 18

gold standard for the diagnosis of blunt cerebral vascular injury

Answer 18

Digital subtraction angiography

Question 19

True or false

In patients with penetrating neck trauma, a careful, structured physical exam is more than 95% sensitive for detecting clinically significant vascular and aerodigestive injuries

Answer 19

True

Question 20

True or false

Nine out of 10 patients with hard signs will have an injury requiring repair and should be rapidly transferred to the operating room or angiography suite

Answer 20

True

Question 21

__________________are the most common cervical injury and the leading cause of death from penetrating neck trauma

Answer 21

Vascular injuries

Question 22

Although angiography remains the gold standard for investigating penetrating neck vascular injuries, ________ is now the first-line imaging modality.

Answer 22

MDCTA (multidetector CT angiography)

Question 23

In a penetrating neck trauma, if a patient is unstable, what is next step?

Answer 23

OR or Interventional angiography to repair injury

Question 24

In a penetrating neck trauma, if there is suspicion for pharyngo- esophageal injury, next step is?

Answer 24

Esophagram or esophagoscopy (100% sensitivity)

Question 25

In a penetrating neck trauma, if there is suspicion for laryngo-tracheal injury, what is next step?

Answer 25

Panendoscopy

Question 26

In a penetrating neck trauma, if there is suspicion for vascular injury, what is next step?

Answer 26

CTA or Color Doppler Angiography

Question 27

Screening Criteria for Blunt Cerebral Vascular Injury

Signs and symptoms

Answer 27

• Arterial hemorrhage from nose, neck, or mouth
• Cervical bruit in patients <50 y old
• Expanding cervical hematoma
• Focal neurologic deficit: transient ischemic attack, hemiparesis, vertebrobasilar symptoms, Horner’s syndrome
• Stroke on secondary CT
• Neurologic deficit unexplained by head CT

Question 28

Risk factors for blunt cerebral vascular injury

Answer 28

High-energy transfer mechanism and one of the ff:

—Facial fractures: Le Fort II or III fracture, mandible fracture, frontal skull fracture, orbital fracture
— Cervical spine fracture patterns: subluxation, fractures extending into the transverse foramen, fracture at any level
— Any basilar skull fracture or occipital condyle fracture
— Petrous bone fracture
— Diffuse axonal injury with Glasgow Coma Scale score ≤8
—Concurrent traumatic brain and thoracic injuries
—Neck hanging with anoxic brain injury
— Clothesline type injury or seat belt injury with significant swelling, pain, or altered mental status
— Scalp degloving
—Thoracic vascular injuries
—Blunt cardiac rupture
—Upper rib fractures

Question 29

In Strangulation, the major pathologic mechanism is ______ _________ __________ rather than airway obstruction

Answer 29

neck vessel occlusion