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
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)
21.
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
27.
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
33.
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
39. REFERENCES:
• ROSEN’S Emergency Medicine Concepts and Clinical Practice
• Tintinalli’s Emergency Medicine
• REBELEM.com
• canadiem.org/crackcast
• Google images
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.
