More Related Content
What's hot
What's hot (20)
Similar to Neck trauma
Similar to Neck trauma (20)
Recently uploaded
Recently uploaded (20)
Neck trauma
- 1. Mohammad Kadamany PGY-3 EM Resident King Abdullah Medical City- Makkah
- 2. CASES Which of the following is considered HARD SIGN for aerodigestive or neurovascular injuries following a penetrating trauma? a) Absent radial pulse b) Dysphonia c) Non-expanding hematoma d) Subcutaneous emphysema 23 yo M presents with neck pain after a MVC. On presentation, he complaints of dysphagia and hoarseness. Physical exam reveals anterior neck tenderness, stridor, and crepitus around the neck. What diagnostic modality is BEST to evaluate the potential injury? a) Cervical spine CT scan b) Direct fiberoptic laryngoscopy c) Radiograph of the neck d) Ultrasound of the neck
- 3. 24 yo man presents with a laceration to the right side of the face sustained during a knife fight. There is a large tissue defect over the right parotid gland. Local wound exploration reveals a severed cervical branch of the facial nerve. Paralysis of which muscle is likely to be present? a) Mentalis b) Platysma c) Orbicularis oris d) Orbicularis oculi Which of the following is most commonly involved in penetrating neck trauma? a) Zone I b) Zone II c) Zone III d) Zone IV
- 4. 27-year-old man presents after being hit in the neck. His voice is hoarse and on examination you palpate subcutaneous emphysema. He is in respiratory distress and the decision is made to intubate. Which of the following is the most appropriate technique? a) Blind nasotracheal intubation b) Immediate tracheostomy c) Needle cricothyrotomy d) Orotracheal intubation
- 5. 45-year-old inmate from prison presents with a puncture wound to his neck from an unknown object. On exam, you find a comfortable appearing male who is able to speak clearly. He has a 2-mm punctate wound approximately 3 cm lateral to the thyroid cartilage that penetrates the platysma. You note a small amount of oozing blood. Vital signs are BP 145/93, HR 67, RR 23, and 98% on RA. Which of the following is the most appropriate next step? a) Attempt to locate the oozing vessel and clamp it b) CT angiogram of the neck c) Discharge if asymptomatic after 6 hours of observation d) Transfer to the operating room for surgical exploration
- 6. Which of the following structures is located in Zone 3 of the neck? a) Apex of the lung b) Esophagus c) Parotid gland d) Trachea Violation of which of the following structures defines a penetrating neck injury? a) Mylohyoid muscle b) Platysma c) Sternocleidomastoid muscle d) Subcutaneous tissue
- 7. 23-year-old man is brought to the emergency department by EMS after being stabbed in the neck during a bar fight. He is alert, oriented, and complaining of severe neck pain in a clear voice. His vital signs on arrival are T 36.9C, HR 125, BP 130/80, RR 20. On examination, the patient has a 2 cm penetrating injury to zone II of the right neck with a moderate amount of blood bubbling from the wound. Which of the following is the most appropriate next step in the management of this patient’s injury? a) Admission for bronchoscopy and esophagoscopy b) CT angiogram of the neck c) Immediate orotracheal intubation d) Transfer to the operating room for immediate surgical exploration
- 8. INTRODUCTION • The neck contains vital structures • Injuries to these structures can be life-threatening • Airway compromise • Hemorrhagic shock • Neurological injury • Vascular injury
- 9. ANATOMY
- 12. • Neck trauma has 3 mechanisms: • Penetrating injury • Blunt injury • Hanging/strangulations • These mechanisms are categorized anatomically to: • Laryngotracheal • Pharyngoesophageal • Vascular
- 13. CLINICAL FEATURES • Dyspnea • Dysphonia • Stridor • Drooling • Hematoma • External bleeding • Neurological deficit
- 14. • Penetrating Injuries: • Types of weapons: • Low velocity: knives and glass • High velocity: handguns and shotguns • Blunt Injuries: • MVC • Clothline or during sport games
- 15. MANAGEMENT 1) Penetrating Trauma Depends on anatomical zones, clinical presentations and hemodynamic stability. Airway: The initial priority Bag valve mask? Expect the future compromise Ideally orotracheal intubation with RSI C-collar?
- 16. • Paralysis may theoretically cause airway obstruction by relaxation of muscles (though this is not born out in the literature). • Consider awake intubation or ketamine facilitated intubation (May 2018)
- 17. Breathing: • Consider pneumothorax/hemothorax (zone I) • Thoracotomy: • less than 15 minutes of CPR with penetrating neck trauma. • less than 10 minutes of CPR with any blunt trauma.
- 18. Circulation: • Bleeding is controlled by direct pressure. • To facilitate compression use finger or packing • Avoid wound probing/blind clamping of actively bleeding wounds • Balloon catheter? • Platysma violation with instability indicates a surgical consult.
- 19. Zone I Angiography, esophageal and tracheal evaluations Zone II Surgical evaluation IF HARD SIGNS present Zone III Angiography
- 20. • Air Embolism: • Could be venous or arterial • Suspect it with sudden hypoxia or when coded • Neurological symptoms can be with arterial embolism. • Treatment: • O2 supplement • Start CPR if coded • Position the pt on Trendelenburg and left lateral decubitus • Air aspiration attempt from right heart (from central line)
- 22. • 2) Pharyngoesphageal Trauma • Its rare • Mostly due to penetrating injury involving cervical segment. • Blunt injury is due to hyperextension or cervical fracture injuries. • Why important?
- 23. • Contrast esophagography and barium • Endoscopy after negative contrast • Both can give sensitivity up to 100% • CT scan rule? • Management: • ABCD • Start antibiotics (tazo 3.75 gm every 6 hours) • NPO • Surgical consult
- 24. 3) Laryngotracheal Trauma • It is rare • Mainly due to blunt trauma (clothline, near hanging, sport games) • The most serious injury is cricoid fracture • Presents with: • Dysphonia, dysphagia, stridor, laryngeal crepitus, wound bubbling
- 25. • Plain radiograph is helpful in detecting subcutaneous emphysema • Laryngoscopy or flexible nasopharyngoscopy • Rigid bronchoscopy for lower airway (in OR) • Neck CT scan: • Approaching sensitivity 100 % • Gives you detailed laryngeal integrity and surrounding organs • Use 1-mm cuts for anterior neck soft tissue
- 26. • Management: • Airway: • Early laryngoscopy to determine the need for secured airway. • Awake fiberoptic oral intubation is the best. • If not available, video laryngoscopy • If “awake” not feasible, RSI with “double set-up” • Tracheostomy if the pt in OR • Disposition: • Admission intubated patients to ICU. • No identifiable injury, can be observed 12 hours and d/c • Analgesia, steroid, antibiotic, vocal rest, anti reflux, clear diet
- 28. • 4) Vascular Trauma • Vessels at risk are carotid, subclavian, and vertebral arteries. Internal and external jagular veins • Could be penetrating/blunt trauma • The primary concerns are intimal tear, pseudoanurysms or dissection. • mortality occurs via exsanguination, hematoma expansion, embolization of a foreign body • 80% of patients present with penetrating injuries and HARD SIGNS • CNS symptoms are delayed 10-72 hr post injury
- 29. • Neck CTA has sensitivity and specificity reaching 98-100% on both penetrating and blunt trauma. • Other films like neck plain films, dupplex ultrasound, CXR
- 30. • Management: • Goal is treating life-threatening hemorrhage and preventing stroke. • Penetrating inj: • Not well-determined • Surgical repair is common • Ligation may overcome the repair • Endovascular repair for vertebral arteries
- 31. • Blunt inj: • Art. injuries treatment depends on mechanism, type of injury, and location • Modalities include anticoagulation, surgery and observation • Vascular/neurosurgery consult • Appropriate treatment decrease stroke rate from 25% to 4%
- 32. • 5) Nervous System, Reteropharyngeal Trauma • Damage to brachial plexus, cervical sympathetic chain, and cranial nerves. • Presents with neurogenic shock (brady, hypotensive and paraplegic) • Can be present with hoarseness (recurrent laryngeal nerve) • Isolated reteropharyngeal hematoma (from whiplash mechanism) • Management: • ABCD • Surgical/ neurosurgical consult
- 34. 6) Hanging and strangulation • What’s the difference? • Judicial and non-judicial hanging • Manual and ligature strangulation • Postural strangulation • Survivors of hanging can suffer sequelae in other systems: hypoxic- ischemic brain injury and pulmonary edema.
- 35. • Ligature marks, fingernail scratches, abrasions • Tardieu's spot (correlated with asphyxia death) • Thyroid cartilage or hyoid bone fractures • Late neurological sequelae • Brain CT and neck CTA for survivors
- 36. • Management: • As with blunt injury (ABCD) • For survivors who develop pulmonary edema (ARDS protocol). • Hypothermia protocol for hypoxic brain injury? • Admit survivors with psychiatric consultation
- 37. TAKE-HOME MESSAGE • Most patients with blunt or penetrating injuries warrant admission • Hard/Soft signs • ALL unstable platysma violation pts should be admitted • Careful observation for vascular/neurological (delayed) • Laryngotracheal injury be worried about AIRWAY • Difference between hanging and strangulation • Survivors need psychiatric assessment
- 38. BACK TO PRETEST QUESTIONS Go to cases
- 39. REFERENCES: • ROSEN’S Emergency Medicine Concepts and Clinical Practice • Tintinalli’s Emergency Medicine • REBELEM.com • canadiem.org/crackcast • Google images
- 40. QUESTIONS?
Editor's Notes
- A B
- B B
- D
- B
- C B
- D
- Why we bother?
- Transporting the pt to the nearest trauma center. - Secured airway even if the pt looks fine coz it deteriorates rapidly. - Bag can result in emphysema or rarely air embolism - One large series found an overall incidence of 0.4% unstable cervical spine injuries in patients who had sustained penetrating neck injury
- 16-18 French may be helpful during transport to OR
- Because spillage of the gastric contents may lead to abscess and mediastinitis. Delayed diagnosis can increase up the mortality to 20%.
- Without oral contrast is not supported in literatures. Can be used in tracking the bullet Can be sufficient with low probability test High risk should be done with oral contrast
- Which can obstruct the airway
- 1-mm can detect fractures
- emergent laryngoscopy depends on suspected injuries, the patient’s overall status, and the ability to tolerate examination by laryngoscopy under local anesthesia, with or without sedation.
- When symptomatic, carotid injuries cause either transient or fixed contralateral sensory or motor deficits, aphasia, dysphasia, and Horner syndrome 80% of patients present with penetrating injuries and HARD SIGNS 50% of patients with dissection from blunt trauma are asymptomatic
- Anticoagulant either heparin or aspirin which non of them show improving outcome Surgical treatment includes ligation, resection, thrombectomy, endovascular stent placement,
- -Especially VII, IX,X,XI,XII Brown Sequrd Syndrome (ipsilat paralysis and contralat sensory loss) -Isolated very rare but life-threatening due to airway compromise
- -Hanging either complete or incomplete, also whether or not the victim’s feet were totally suspended and the location of the knot -Strangulation either manual or ligature by hand or device compressing the neck independent to the gravity. -Judicial hanging which is falling by gravity and fracture both pedicles of C2 (hangman’s#), and complete cord transection. -Non-judicial hangings frequently occur at less than 2.7 meters, usually inadequate to injure the cervical spine, except in the elderly population -Pulm edema could be neurogenic, post-obstructive, cardiogenic.
- Case series indicate a potential role for induced mild hypothermia in comatose survivors of strangulation One study demonstrated 43% rate of survival to discharge and 6% return of neurological function in hanging pts treated with hypothermia after arrest.