Neck Trauma Management Treatment & Management

In most urban settings, immediate transport of the patient with neck trauma to the closest level I trauma setting is most appropriate because state-of-the-art care frequently necessitates a multidisciplinary approach. Emergency medical personnel should restrict intubation attempts except when anticipating a prolonged transport time; when the patient is apneic, pulseless, or moribund; or when respiratory arrest is imminent.

Providing supplemental oxygen and clearing the airway of all secretions and foreign bodies, including unfastened dentures and loose teeth, frequently prove sufficient, practical, and helpful for the conscious patient. Injudicious attempts to vigorously insert an endotracheal tube may worsen the patient's state by running the risk of utterly marring the airway. Ventilation of the patient with a positive-pressure bag-valve-mask device can exacerbate underlying subcutaneous emphysema, conceivably distorting the airway anatomy and impairing breathing and circulation.

Impregnated gauze should be used to cover sucking neck wounds or lacerations exuding bubbling air.

Patients who sustain significant blunt trauma require cervical spine precautions, including cervical spine immobilization and supine placement of the patient on a backboard. However, based on retrospective studies, the incidence of cervical spine injuries in patients sustaining penetrating neck injuries who are alert, oriented, and lack any focal neurologic findings is very low. ^{[38, 39]} In addition, a cervical collar could potentially obscure an expanding neck hematoma.

Defer removal of helmets or other headgear until neck stabilization has been ensured.

Bleeding from the neck is best controlled with direct pressure. Impaled objects should not be extracted in the field. Intravenous access should be established en route to the hospital. The access should be preferably placed in the extremity opposite the side of the injury in case disruption of the ipsilateral venous circulation has occurred.

Emergency medical reports should relate the mechanism of injury, including the type of weapon involved, estimated amount of blood lost (EBL) at the scene, initial vital signs, noteworthy physical findings, and total transport time.

Initial evaluation and stabilization includes securing the airway, controlling bleeding, providing cervical spine precautions, and identifying life-threatening conditions. Most blunt traumatic neck injuries can be managed nonoperatively. Surgical assessment of penetrating neck wounds usually requires a greater resolve for operative intervention, although prior axioms decreeing surgery as the only option are no longer as absolute. ^[40] However, when an injury violates the platysma, it is sensible and prudent to engage a qualified surgeon or to transfer a stable patient to a trauma center where such care is available. ^{[15, 41, 42]}

Ensure compliance with EMTALA regulations. Transfers from nontrauma centers to trauma centers are considered "medically indicated" transfers because the purpose of each transfer is to obtain the higher level of care necessary to treat a patient's condition.

Airway

Emergency department care of the patient with neck trauma commences with assessment and stabilization of the ABCs, starting with the airway. Unfortunately, the same conditions that compel active airway management also intensify the obstacles to achieving successful intubation. Nonetheless, a wait-and-see attitude merely invites disaster.

Consequently, a preplanned strategy based on the expertise of the available staff, equipment at hand, the patient's clinical condition, and the determined necessity for further testing should be in place before this scenario occurs. An entrenched partnership must exist between all potentially involved departments, especially emergency medicine, surgery, and anesthesiology.

Intubating a patient with penetrating neck trauma may incite gagging or coughing, potentially dislodging a clot and setting off massive bleeding from a previously injured blood vessel. Additionally, existent bleeding and edema rapidly distort the surrounding anatomy, making oral intubation difficult, if not impossible. Nevertheless, assessment of the airway takes priority over all other actions, including those procedures that risk exacerbating hemorrhage. Early preparation by the practitioners treating the patient is crucial. This includes ensuring ease of access to an acceptable suction apparatus and having multiple-sized endotracheal tubes. as well as any tools and supplies necessary to perform the surgical airway procedure, close at hand.

Before intubation, clear the mouth of foreign debris with the fingers or manual suction. Remedy partial airway occlusion originating from the tongue by performing a modified jaw thrust. Never do a head-tilt chin-lift maneuver in a patient with a suspected cervical spine injury.

Perform emergent orotracheal intubation in patients displaying signs of acute or impending respiratory distress, such as perceptible noisy breathing; an inability to suitably handle blood, vomitus, or other bodily secretions; and obvious distortion of any neck landmarks, particularly tracheal deviation or existence of massive subcutaneous air. The choice of technique depends on the expertise of the attending staff and the capability to perform a surgical airway procedure. Despite concerns about converting a partially obstructed airway into a completely obstructed airway, a retrospective series by Mandavia et al proved rapid sequence intubation to be safe and effective when performed by emergency physicians trained in this skill. ^[43]

An awareness of potential laryngeal damage is imperative prior to intubation, even when the airway must be emergently secured. A neck hematoma can obscure landmarks, in addition to causing the danger of precipitating life-threatening exsanguination. Overwhelming suspicion for laryngeal injury directs execution of a surgical airway procedure to avoid injudicious endeavors at oral intubation that could sever a tenuously attached trachea or larynx, conceivably causing a catastrophe consequent to complete loss of the airway if the larynx detaches and dislodges into the chest.

Several large case series such as that by Shatney et al ^[44] demonstrate the safety of oral intubation with cervical in-line stabilization, provided that direct laryngoscopy and intubation are performed in a gentle, atraumatic manner and explicit cervical spine immobilization is maintained. This is the preferred approach for the accomplished intubator in the patient with blunt trauma with suspected cervical spine injury.

Alternative techniques for securing the airway include fiberoptic intubation, gum elastic bougie, percutaneous transtracheal intubation, and wire-guided retrograde intubation.

Fiberoptic intubation is a sensible course of action, especially for patients thought to have sustained a cervical spine injury or who exhibit gross distortion of the airway. Limitations include clinician inexperience, lack of necessary equipment, and copious bleeding or secretions. Percutaneous transtracheal intubation, also referred to as translaryngeal ventilation, is a quick and relatively simple technique in which a needle is inserted through the cricothyroid membrane and attached via a Y connector to an oxygen supply of at least 50 psi. This procedure is contraindicated when transection of the trachea or damage to the cricoid cartilage or the larynx is strongly suspected. Barotrauma may occur with percutaneous ventilation. Retrograde tracheal intubation is an invasive procedure that may be suitable when excessive amounts of blood or secretions preclude fiberoptic intubation or when neck movement must be restricted.

Breathing

Signs or symptoms of respiratory embarrassment compel consideration for a hemothorax or a pneumothorax. Zone I injuries may breach the chest cavity. Ventilatory distress that persists beyond competent intubation indicates a possible tension pneumothorax, which requires needle decompression and chest tube placement. Occlusion of the tracheobronchial tree, whether due to a foreign body or iatrogenic, is another cause of ventilatory problems.

Circulation

Bleeding that originates from neck trauma should be controlled by direct pressure. Do not blindly clamp a transected vessel, because inadvertent injury to adjacent structures or extension of blood vessel damage may occur. Never probe, cannulate, or locally explore these wounds in the ED, because these actions may cause an air embolus or dislodge a clot and provoke bleeding.

Do not remove objects protruding from the neck in the ED.

Concurrent with checking bleeding, establish intravenous access with at least 2 large-bore catheters (14 or 16 gauge). If injury to the brachiocephalic or subclavian vein is a possibility, place 1 intravenous access site in a lower extremity site and another access site in the upper extremity on the uninjured side.

Placing the patient in a mild Trendelenburg position to decrease the risk of air embolization may be advantageous.

In selected cases, bleeding that cannot be controlled or reached with direct pressure may benefit from balloon tamponade. Insert a Foley catheter into the wound. Direct it toward the site of bleeding, and inflate the balloon until bleeding resolves or moderate resistance is noted. As an example, for zone I injuries, slide in a Foley catheter toward the pleural cavity, and then inflate the balloon with sterile saline and retract it, striving to compress the injured subclavian vessel against the first rib or clavicle. ^[21]

On rare occasions, such as with wounds in the pharynx, applying direct pressure to wounds may be impractical. These wounds may necessitate a cricothyroidotomy with subsequent packing of the pharynx as a temporary strategy.

Disability

Blunt neck trauma causes a wide spectrum of injuries ranging from a minor contusion or abrasion to life-threatening scenarios. Cervical spine injury remains a continual concern, especially for patients sustaining significant blunt trauma to the head and/or neck.

Not only is the spinal cord vulnerable to injury, but other neural pathways are as well, such as the phrenic, recurrent laryngeal, and lower lying cranial nerves, along with the brachial plexus. Additionally, detection of a neurologic deficit may signify damage to the carotid or vertebral artery with subsequent CNS ischemia.

Exposure

To view the anterior part of a neck that is concealed by a cervical collar, appoint an assistant to maintain the neck in a neutral position, and then remove the anterior aspect of the collar and proceed with the evaluation.

Expose and observe the patient's entire body to avoid overlooking other potentially lethal injuries.

Miscellaneous

Once the patient is considered somewhat stable, the next step is to gently evaluate the neck wound to determine if the platysma has been violated. In this regard, the platysma is treated like the peritoneum of the abdomen; if it is violated, involvement of a qualified surgeon is mandatory. Even the most innocuous-appearing wound of the neck should not be probed or locally explored in the ED once a breach in the platysma is confirmed, because a real risk of provoking clot dislodgment with subsequent secondary hemorrhage exists.

If there are no findings necessitating emergent surgeries, confer with a qualified trauma surgeon about further ED evaluation.

If the condition of a patient with penetrating neck trauma deteriorates to a state of cardiopulmonary arrest and the facility and the staff are qualified, perform an emergent thoracotomy to gain better control of the bleeding.

Consider cross-clamping the aorta and aspirating the right ventricle to forestall advancement of an air embolus.

It is usually best to avoid inserting a nasogastric tube until the airway is secured.

Despite the availability of advanced medical imaging techniques, foreign body detection remains a challenge, as it is dependent on the foreign body material, the affected anatomic site, and the severity of the injury. Therefore, obtaining a detailed history of the circumstances leading to trauma is essential when foreign objects are not visible during clinical examination. Precise detection of the foreign body, determination of its anatomic position, and evaluation of its effects on surrounding structures are vital, especially when impalement injuries of the head and neck area are managed. An interdisciplinary planning approach is essential prior to removal of the foreign object. Finally, tension-free anatomic adaptation of corresponding structures is crucial for maintaining and restoring aesthetics and function. ^[45]

Consult an experienced trauma surgeon emergently once platysmal violation is confirmed. Additional consultants should be prioritized with guidance from the trauma surgeon who will oversee the patient's care.

Ordinarily, urgent surgical exploration of a penetrating wound to the neck is indicated for the following:

• Continued blood loss, expanding hematoma, hypovolemic shock, and/or pulse deficit

• Airway obstruction, impending airway obstruction, open trachea, and/or air bubbling from the wound site

• Neurologic deficit

• Blood in the aerodigestive tract, hemoptysis, and/or hematemesis

• New-onset bruit

Observe patients with all but the most trivial of neck wounds for delayed onset of symptoms. Platysma violation usually justifies admission for 24 hours of observation to avoid missing occult injuries, particularly vascular and esophageal wounds. Decisions regarding the need to admit a patient with blunt neck trauma are based on the presence or absence of signs and symptoms, as well as the patient's underlying physiologic status and factors such as the availability of care, extent of care warranted, and willingness of responsible parties to participate.

Many patients are discharged with the diagnosis of whiplash injury, which is neck pain following sudden flexion-extension of the head (eg, with a rear-end motor vehicle accident). By definition, whiplash injury implies that bony damage or other significant injuries are excluded. In addition, the pain originates from a stretching and bruising of the neighboring musculature and supporting ligaments.

Lacerations that are superficial to the platysma in an otherwise asymptomatic patient should be managed in the same way as cuts found elsewhere on the body. Clean lacerations may be sutured as late as 12-18 hours after injury, since the neck is ordinarily exceptionally well perfused.

Standing protocols dictating the treatment of patients with neck trauma must be in place. Such guidelines should indicate which patients require emergent surgery, transfer, or further workup.

A major disadvantage of exploring all penetrating neck injuries with platysma violation is a nontherapeutic exploration in approximately 50% of cases. This results in unnecessary costs and nonessential invasive procedures. Studies (eg, those by Demetriades et al ^[46] and Ngakane et al ^[47] ) suggest that the majority of patients with penetrating neck trauma can be treated nonoperatively. No definitive recommendation exists, and treatment protocols should be based on a multidisciplinary agreement within the institution. However, because of the prospect of occult injuries with zone I and III wounds, a relatively aggressive workup is warranted. The definitive evaluation and management of penetrating trauma in particular continues to evolve.

Decisions regarding whether to ligate or repair arterial injuries rely on the presence or absence of a major neurologic deficit (coma and/or paralysis); some surgeons prefer to avoid the danger of reperfusion injury of the brain.

Embolization may halt bleeding from a damaged vessel in the neck. If the patient's vital signs are not stabilized, death in the radiologic suite is a real risk. Temporary occlusion of the blood vessel may be achieved by insertion of a gelatin sponge or coil.

Airway obstruction may result from evolving tracheal and/or laryngeal edema or stenosis. Vocal cord paralysis and voice change also may follow laryngeal trauma.

Swallowing dysfunctions may affect patients with neck trauma. Aspiration of material (eg, blood, vomitus) is always a possibility. Patients who survive the initial strangulation injury may succumb to pulmonary edema or bronchopneumonia.

Unrecognized vascular injury may lead to delayed exsanguination (rupture of clot with hemorrhage), clot embolization or thrombosis, and/or formation of a false channel (pseudoaneurysm) or arteriovenous fistula (both of which can evolve into delayed hemorrhage). Vascular injuries subsequent to blunt trauma specifically are associated with a high complication rate. Approximately 10% of patients are asymptomatic in the first hour.

Soft tissue necrotizing infections caused by mixed bacterial organisms may originate from contamination of the neck or extravasation from oral wounds. Sepsis, mediastinitis, and cervical osteomyelitis may occur.

Fistulas include tract formation between the trachea and the innominate arteries (tracheoinnominate [TI] fistula), the trachea and the brachiocephalic artery (potential for a catastrophic hemorrhage within the tracheobronchial tree), and the esophagus and the skin (esophagocutaneous fistula).

Complications associated with arteriography range from arterial wall injuries (eg, intimal flaps, thrombosis, severe vascular spasm) to neurologic impairment, anaphylactic reaction, and groin hematoma (may lead to femoral artery occlusion).

Air embolism is an infrequent, seldom-mentioned complication that arises from tears in the major neck veins. Penetrating neck trauma may precipitate an air embolism. Depending on where the embolus settles, positioning the patient may lessen the chance of embolus propagation. Suspect this entity in patients developing unexpected hypotension and/or arrhythmia, especially in the setting of an increase in central venous pressure.

Lead intoxication is an unusual problem that occurs subsequent to a bullet remaining lodged in the neck, usually in a joint space. Warning signs and symptoms include abdominal pain, nephropathy, and unexplained anemia.

Zone I wounds are often associated with thoracic injury causing a pneumothorax, hemothorax, or tension pneumothorax.