Neck Trauma Management Clinical Presentation

Because many critical organs and structures are at risk from neck trauma, clinical manifestations can vary greatly. The presence or absence of symptoms can be misleading, serving as a poor predictor of underlying damage. For example, only 10% of patients with blunt vascular damage develop symptoms in the first hour.

Use all available sources when trying to establish the mechanism of injury. Question the patient, involved bystanders, and prehospital personnel. Clarify events surrounding the traumatic event, establish the amount of time that elapsed since the injury, and confirm the patient's baseline condition. Determine the amount of blood that was lost at the scene, whether the patient lost consciousness, and if there is any evidence of recent drug or alcohol ingestion.

When neck trauma results from a motor vehicle crash, inquire about seat belt use, location of the patient in the car (driver or front or back seat passenger), deployment of an air bag, and magnitude of car damage (eg, intrusion, steering column and windshield intact or broken).

In the event of a penetrating trauma, try to verify details about the weapon used, such as type and size of knife or type and caliber of gun. For patients with injuries due to hanging, try to determine the suspension time (when the patient was last seen), drop height, ligature used, history of alcohol or drug abuse, and history of suicide attempts.

Characterize pain (eg, location, nature, intensity, onset, radiation), and document the nature and location of all stated injuries. Cardiovascular manifestations range from bleeding to symptoms normally associated with a cerebrovascular accident. Symptoms relating to the aerodigestive tract include dyspnea, hoarseness, dysphonia, and dysphagia. CNS problems include paresthesias, weakness, plegia, and paresis.

A standard approach to the patient with neck trauma is advised. The primary survey should consist of determination of airway patency, breathing, and adequacy of circulation. Keep in mind that loss of patency of the airway may occur precipitously. The patient should be fully exposed and any disabilities noted.

On secondary survey, the neck should be methodically examined, searching for clues that indicate damage to vital contents. The sensitivity of the physical examination to identify all significant neck damage remains controversial. Some experts in the field of trauma assert that physical examination alone is sufficient to assess zone II for injury, while others believe that diagnostic testing is mandatory.

A single examination is not sufficient, because the onset of signs of injury may be delayed and progressive with neck trauma. Carefully inspect the neck for a breach of the platysma. Invested by the most superficial fascia, violation of the platysma serves as a marker for possible serious penetrating neck wounds. Any violation of the platysmal muscle should be an alert to the potential for grave damage to the contents of the neck. If the platysma is violated, determine whether the wound lies anterior (anterior triangle) or posterior (posterior triangle) to the sternocleidomastoid muscle, and determine in what zone the injury is found. Try to specify the direction of the wound tract (eg, toward or away from the midline or clavicle). About 50% of cases of penetrating neck trauma in which the platysma is violated have no further injury. If the platysma is clearly not violated by a penetrating injury, the patient can be safely cleared of a significant underlying injury.

Consider an arterial injury of the neck in patients manifesting any degree of gross bleeding or presence of a hematoma. Hard signs of an arterial injury include a large expanding hematoma, severe active or pulsatile bleeding, shock unresponsive to fluids, signs of cerebral infarction, presence of a bruit or thrill, and diminished distal pulses. Virtually all patients with hard signs of an arterial injury require operative repair.

Soft signs, such as a nonexpanding hematoma and paresthesias, do not improve the predictive value of an arterial injury more than indicating the proximity of the wound to a major vessel.

The presence of a pulse does not exclude a vascular injury, and absence of a pulse is not diagnostic of vascular damage. Clinical findings are lacking initially in almost one third of patients with an arterial injury of the neck. Nearly one third of carotid artery injuries are associated with a central neurologic deficit.

Unnecessary probing or manipulation of the wound or performing any action that may cause the patient to gag, choke, or cough is discouraged. Any of these reactions may dislodge a clot and provoke a life-threatening hemorrhage.

Perforation of the pharynx or the esophagus following blunt neck trauma occurs infrequently (present in approximately 10% of trauma admissions). Initially, the patient may have no complaints, with the physical examination often failing to reveal any injury. Indirect signs of aerodigestive injuries include hematemesis, odynophagia, subcutaneous emphysema, and blood in the saliva or in the aspirate of a nasogastric tube. Because the esophagus lacks a serosa layer, it is more susceptible to iatrogenic injury such as following endoscopy, passage of a nasogastric tube, or inadvertent esophageal intubation. Esophageal perforation is the most serious and rapidly fatal trauma-induced perforation of the GI tract.

Examine the patient who has been strangulated. Note location and depth of marks, petechial hemorrhages of the skin and subconjunctival tissue (Tardieu spots), noisy or impaired respiration or phonation (eg, stridor, hoarseness, poor air movement), and palpable crepitus or tenderness over the larynx and trachea. Check for neurological deficits.

Signs of spinal cord or brachial plexus injury

Brachial plexus injuries sustained from blunt trauma tend to involve the upper nerve roots (C5-C7), diminishing the capacity of the upper arm while sparing strength and sensation of the lower arm. ^[24]  A radical avulsion of the brachial plexus results in a flaccid, numb extremity.

Quadriplegia occurring with complete transection of the spinal cord manifests as an absence of all motor, sensory, and reflex function below the level of injury. Bilateral neurologic findings imply a spinal cord injury until proven differently.

Pathologic reflexes, such as the Babinski reflex (extension of big toe) and Hoffmann sign (overactive muscle-stretch reflex), may be present.

Brown-Séquard syndrome results from hemisection of the spinal cord, causing ipsilateral motor paralysis with contralateral sensory deficits.

Priapism and loss of the bulbocavernous reflex may occur, and rectal tone may be poor.

Urinary retention, fecal incontinence, and paralytic ileus can occur from spinal cord damage.

Horner syndrome (ipsilateral miosis, enophthalmos, anhidrosis) results from disturbances of the stellate ganglion.

Neurogenic shock is a diagnosis of exclusion and is characterized by persistent bradycardia despite hypotension.

Hypoxia and hypoventilation can follow disruption of phrenic innervation to the diaphragm.

Signs of larynx or trachea injury

Signs of a laryngeal or tracheal injury include the following ^[7] :

• Voice alteration

• Hemoptysis

• Stridor

• Drooling

• Sucking, hissing, or air frothing or bubbling through the neck wound (It may be provoked by coughing.)

• Subcutaneous emphysema and/or crepitus

• Hoarseness

• Dyspnea

• Distortion of the normal anatomic appearance (eg, loss of normal landmarks, asymmetry, flattened thyroid prominence, tracheal deviation)

• Pain on palpation or with coughing or swallowing

• Pain with tongue movement implies injury to the epiglottis, hyoid bone, or laryngeal cartilage

• Crepitus (this hallmark sign of disruption to aerodigestive tract is noteworthy in only one third of cases)

Signs of penetrating injuries of the heart, aorta, and great vessels

Signs of penetrating injuries include the following:

• Hemorrhage, usually associated with large wounds (eg, gunshot wounds [GSWs])

• Massive hemothorax

• Hypotension

• Tamponade (if intrapericardial portion of aorta is injured)

• Weak or absent carotid or brachial pulse

• Paradoxical pulse (decrease in systolic BP with inspiration)

• Bruit

• Cervical or supraclavicular hematoma

• Bleeding from the entrance wound

• Upper extremity ischemia

• Coma

• Hemiparesis

• Respiratory distress secondary to tracheal compression

Signs of tracheobronchial or lung injury

Signs of tracheobronchial/lung injury include the following:

• Subcutaneous emphysema

• Cough

• Respiratory distress

• Hemoptysis, usually secondary to a disrupted bronchial artery

• Tension pneumothorax

• Continuous air leak persisting after chest tube insertion

• Mediastinal crunch (Hamman crunch)

• Intercostal retractions

• Decreased breath sounds

• Hyperresonance to percussion of the contralateral hemithorax, associated with hyperinflation of the unaffected lung

• Tachypnea

• Agitation

• Hypotension

• Tachycardia

• Hypoxia

• Shifting of the trachea and the apical heartbeat away from the injured side

Signs of carotid artery injury

The following are signs of a carotid artery injury:

• Decreased level of consciousness

• Contralateral hemiparesis

• Hemorrhage

• Hematoma

• Dyspnea secondary to compression of the trachea

• Thrill

• Bruit

• Pulse deficit

Signs of jugular vein injury

Signs of injury to the jugular vein include the following:

• Hematoma

• External hemorrhage

• Hypotension

Signs of cranial nerve injuries

Signs of cranial nerve injuries include the following:

• Facial nerve (cranial nerve VII) - Drooping of the corner of the mouth

• Glossopharyngeal nerve (cranial nerve IX) - Dysphagia (altered gag reflex)

• Vagus nerve (cranial nerve X, recurrent laryngeal) - Hoarseness (weak voice)

• Spinal accessory nerve (cranial nerve XI) - Inability to shrug a shoulder and to laterally rotate the chin to the opposite shoulder

• Hypoglossal nerve (cranial nerve XII) - Deviation of the tongue with protrusion

• Thoracic duct injury: This is usually asymptomatic and tends to be an incidental finding during surgical exploration.

Signs of esophagus and pharyngeal injury

The following signs suggest esophageal or pharyngeal injury:

• Dysphagia

• Bloody saliva

• Sucking neck wound

• Bloody nasogastric aspirate

• Pain and tenderness in the neck

• Resistance of neck with passive motion testing

• Crepitus

• Bleeding from the mouth or nasogastric tube