- Published on
Emergency and Acute Medicine – Neck Trauma, Blunt, Anterior
Blunt anterior neck trauma can result in injury to multiple critical structures, including vascular, laryngotracheal, pharyngoesophageal, neurologic, and cervical spine components. Vascular injuries may involve the carotid or vertebral arteries and include intramural hematoma, intimal tear, thrombosis, pseudoaneurysm, hemorrhage, or expanding neck hematoma. Laryngotracheal injuries include fractures of the hyoid bone, thyroid or cricoid cartilage, cricotracheal separation, vocal cord disruption, arytenoid dislocation, and tracheal hematoma or transection. Pharyngoesophageal injuries may present as hematoma or perforation of the pharynx or esophagus. Neurologic injury can involve the thoracic sympathetic chain causing Horner syndrome, the vagus or recurrent laryngeal nerves, cervical nerve roots, or spinal cord. Cervical spine fractures or dislocations may also be present.
The most common etiology is motor vehicle collisions, particularly frontal impacts in unrestrained occupants striking the dashboard or steering wheel (“padded dash syndrome”), or from shoulder harness–related shearing injury. Other causes include assault with blows to the anterior neck, “clothesline injuries” from motorcycles or recreational vehicles striking suspended wires or cords, and strangulation. In children, the proportionally larger head increases risk for acceleration–deceleration injury, and intraoral trauma to the soft palate may lead to carotid artery thrombosis.
Clinical presentation varies by injured structure. Vascular injury may cause hemorrhage, ecchymosis, edema, carotid bruit or thrill (highly suggestive of vascular injury), and delayed neurologic deficits. Laryngotracheal injury may present with hoarseness, aphonia, dyspnea, inspiratory stridor, labored breathing, air hunger, subcutaneous emphysema, and anterior neck tenderness. Pharyngoesophageal injury may cause dysphagia, odynophagia, hematemesis, blood in saliva, and delayed infection or sepsis. Neurologic injury may manifest as central or peripheral deficits. History should focus on mechanism, force, associated symptoms, and injuries beyond the neck, as blunt neck trauma is commonly associated with head and chest injuries.
Physical examination must prioritize airway protection and patency. The neck should be inspected for hemorrhage, hematoma, ecchymosis, edema, and anatomic distortion, auscultated for carotid bruits or stridor, and palpated for tenderness or subcutaneous emphysema. A complete neurologic examination is essential to detect ischemic events, spinal cord injury, or peripheral nerve damage, along with a full trauma examination for associated injuries.
Workup depends on clinical findings. Laboratory studies may include type and cross-match, CBC, and renal function prior to contrast imaging. Cervical spine and lateral neck radiographs have limited value but may show prevertebral swelling, subglottic narrowing, subcutaneous air, or calcified cartilage fractures. Chest radiograph is useful for detecting pneumothorax or pneumomediastinum. Carotid duplex ultrasonography is a rapid, noninvasive screening tool but is operator dependent and limited above the bifurcation. CT is useful in stable patients to evaluate laryngotracheal injury, cartilage disruption, and cervical spine trauma. CT angiography and magnetic resonance angiography have high specificity but limited sensitivity; four-vessel angiography remains the gold standard for arterial injury evaluation. Indications for angiography include carotid bruit, expanding neck hematoma, neurologic deficit with normal head CT, Horner syndrome, or decreased level of consciousness. Fiberoptic laryngoscopy can assess airway injury and assist with intubation, while suspected esophageal injury should be evaluated initially with a contrast swallow study. Unstable patients require immediate surgical intervention.
Prehospital and initial management focus on vigilant airway monitoring, as edema or hematoma may rapidly compromise the airway. Orotracheal intubation is preferred, while blind nasotracheal intubation should be avoided due to distorted anatomy and risk of hematoma rupture. Cervical spine stabilization is mandatory. Immediate airway control is indicated for respiratory distress, stridor, air hunger, or expanding neck hematoma. Cricothyrotomy or emergent tracheostomy may be required if intubation fails, but is contraindicated when bruising or hematoma overlies the thyroid or cricoid cartilage. Unstable patients should proceed directly to the operating room.
Emergency department management requires early surgical consultation for suspected vascular, tracheal, or esophageal injuries, with immediate repair for symptomatic vascular, tracheal, pharyngeal, or esophageal injuries. Laryngeal injuries may not always require immediate surgery. Anticoagulation is often recommended for vascular injuries to reduce thrombosis and improve neurologic outcomes, but only after surgical consultation. Prophylactic antibiotics with anaerobic coverage are indicated when esophageal injury is present.
Patients who are symptomatic, have abnormal imaging, or sustained significant blunt mechanisms require admission and observation for at least 24 hours, with ICU admission for suspected airway or vascular injury. Patients on anticoagulation should be observed for delayed neck hematoma. Only those with trivial injury and negative evaluation may be discharged with strict return precautions for delayed airway, vascular, or neurologic symptoms. Key pitfalls include underestimating delayed vascular injury, failing to anticipate a difficult airway, and missing associated injuries; preparation for airway deterioration and early specialty involvement are essential.
0 Comments
