Episode 173.0 – Blunt Neck Trauma

25 snips

Nov 25, 2019

Delve into the intricacies of blunt neck trauma, revealing its common causes like motor vehicle collisions and strangulation. The discussion emphasizes the critical nature of airway management and the structured assessment necessary to prevent complications. Explore the evaluation of vascular and laryngotracheal damage, as well as treatment strategies for blunt cerebrovascular injury. The conversation also highlights the importance of advanced imaging for detecting rare injuries and the need for teamwork among trauma specialists.

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Episode notes

Intro

00:00 • 3min

Assessing Blunt Neck Trauma: Risks and Considerations

03:03 • 2min

Identifying and Managing Blunt Cerebrovascular Injury

04:37 • 2min

Understanding Blunt Neck Trauma and Its Complications

06:25 • 2min

Management of Pharyngoesophageal and Laryngotracheal Injuries

08:01 • 4min

We go into one of the more complex injuries – blunt neck trauma.

Hosts:
Audrey Bree Tse, MD
Brian Gilberti, MD

Download One Comment Tags: Trauma

Show Notes

Overview

Blunt neck trauma comprises 5% of all neck trauma
Mortality due to loss of airway more so than hemorrhage

Mechanism

MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact
Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)
Direct blows: assault, sports, falls

Initial Management/Primary Survey

Airway
- Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise
- Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
- Assume a difficult airway
Breathing
- Supplemental oxygen
- Assess for bilateral breath sounds
- Can use bedside US to evaluate for pneumothorax or hemothorax
Circulation
- Assess for open wounds, bleeding, hemorrhage
- IV access
Disability
- Maintain C-spine immobilization
- Calculate GCS
- Look for seatbelt sign

Secondary Survey

Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation
Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)

Types of Injuries

Vascular injury

- Overview

- - Carotid arteries (internal, external, common carotid) and vertebral arteries injured
  - Mortality rate ~60% for symptomatic blunt cerebral vascular injury
- Mechanism
  - Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation
  - Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections
- Clinical Features
  - Most patients are asymptomatic and do not develop focal neurological deficits for days
  - if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)
  - specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)

Tintinalli 2016

Diagnostic Testing
- Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)
  - <80% sensitive but 97% specific
  - Also images aerodigestive tracts and C-spine (unlike angiography)
- Followed by Digital Subtraction Angiography (DSA) for positive results or high suspicion
  - Angiography is invasive, expensive, resource-intensive, and carries a high contrast load
Management
- Antithrombotics vs. interventional repair based on BCVI grading system
- Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology
- All patients with blunt cerebral vascular injury will require admission