Blunt Anterior Neck Injury
Current diagnostic and management recommendations for blunt anterior neck trauma – including injuries to laryngotracheal complex, the vasculature of the neck, and esophagus.
- Blunt injuries are more common than penetrating neck injuries.
- Wide range of incidence reported: 1 in 2400 – 1 in 30,000 visits to ED1,2 .
- There is no firmly established diagnostic approach for blunt anterior neck injuries.
- Many cases of patients with initial ‘normal’ exam who decompensate over 48h.
- This review excludes circumferential injuries (hanging, strangulation) and spinal injuries.
5 questions to ask:
- What force or pattern of injury was applied to the neck?
- Direct blow (sports, MVC) –focus on laryngotracheal injury +/- vascular injury +/- esophageal injury (latter is only relevant in very high force mechanisms such as clothesline injuries).
- Indirect forces (hyperextension, hyperflexion, rotational) – need to direct focus on assessing for vascular injuries.
- Strangulation (forensics groups together manual ligature, ligature with ropes, and other ‘chokeholds’ such as knee on the neck).
- What was the strength of force applied? (low, medium, high).
- What structures were directly under the impact of the force?
- Was the force isolated, sustained, or repetitive?
- What is the background of your patient? (pediatric vs geriatric).
Case 1: Adult patient presents with an isolated direct blow with a hockey stick going high speed in anterior midline neck at the level of cricoid.
What to look for on clinical exam?
- Signs: resp distress, open wound, abrasion/bruising, swelling/hematoma, petechiae, drooling, voice changes, hemoptysis, stridor, bruits, thrills, subcutaneous (SC) air, palpable cartilage defect, neuro deficit.
- Symptoms: pain, odynophagia, dyspnea, cough, dysphagia.
You find that your patient has no immediate respiratory distress but you are concerned for laryngotracheal injury.
How and in what order to best confirm this? Scan vs. Scope?
- This must be balanced with other potential injuries in trauma patient (ie. obvious hemodynamic instability), but expert opinion recommends laryngoscopy performed by Otolaryngologist BEFORE patient goes to CT scan3,4,5,6.
- The issue with obtaining a CT before a scope is the risk of possible decompensation in CT scan (ie. expansion of edema/hematoma).
- If in centre with CT capacity but no ENT, liaise with ENT at referral center about whether to scan at your site or directly transfer patient.
- If at a rural centre with no CT capacity, pt should either be admitted for monitoring or transferred to a referral center with ENT.
- Even patients with a relatively ‘normal’ exam should have period of observation ranging between 6-48 hours as many reports of delayed decompensationIf patient has obvious respiratory distress, how does one best secure the airway in a patient with laryngotracheal injury?
- Expert opinion recommends low tracheostomy performed by specialist 4,5,6.
- If this cannot be performed, fiberoptic awake intubation to secure the airway4,5,6.
- If this cannot be performed, there is a good track record of success by ER physicians with endotracheal intubation of patients with laryngotracheal trauma.
- Tips for intubation4,5,6:
- Use awake approach.
- Be mindful of creating false passage with tube through partial tear of the larynx.
- Avoid LMA – can increase SC air and given the potentially altered anatomy, there is an increased risk of causing complete airway obstruction.
- Avoid BVM – can increase SC air.
- Avoid cric.– often unsuccessful as injury is at this level or distal to it.
- Inflate cuff BELOW level of injury.
- If you see an open wound in the neck, still try to secure airway through oral approach as opposed to a surgical airway.
- If you see an open wound with partial tracheal transection – secure distal end of the trachea with a towel clip in case of progression to complete transection.
- Post intubation: expert opinion recommends Abx, PPI, humidified air, steroids.
- Tips for intubation4,5,6:
Case 2: 60yr presents after MVC approx. 75km/hr with a normal level of consciousness, normal vital signs. You have excluded c-spine injury and other injuries but she has a seatbelt sign across L anterolateral neck.
- When should I worry about screening for blunt neck vascular injury (BNVI)?
- Vascular injuries may arise from direct blows or more frequently indirect forces impacting the head and neck
- They are reliably diagnosed with CT angiogram of the neck7,8
- The Eastern Association for the Surgery of Trauma (EAST) guidelines7 recommend using an Expanded Denver Criteria for imaging (https://www.east.org/education-career-development/practice-management-guidelines/details/blunt-cerebrovascular-injury)
- While these criteria are very inclusive, Bruns et al later performed a retrospective study suggesting that some patients would still be missed using the Denver Criteria8
- For patients with a cervical seatbelt sign (bruising or abrasions caused by seatbelt superior to the clavicle), it is recommended to do a CT angiogram only if the patient has swelling around the area or altered LOC7,9,10.
How do I manage a confirmed vascular injury?
- Blunt neck vascular injuries are classified ranging from Grades 1 (slight intimal disruption) to Grade 5 (active extravasation)
- EAST guidelines recommend7:
- Grades 1 and 2 – use of ASA/LMWH
- Grades 3 and 4 – involvement of neuro-interventionalist
- Grade 5 – emergent surgery
When do I worry about esophageal injuries?
- The esophagus is relatively protected and injuries are very rare
- In cases of very high mechanism direct blow, such as clothesline injuries, esophageal injuries should be ruled out with an endoscopy +/- CT esophageal swallow
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- There is no Level 1 evidence for diagnosis and management of blunt anterior neck injuries
- There is only Level 3 recommendations directing diagnosis and management recommendations of blunt laryngotracheal injury including obtaining a laryngoscopy prior to CT scan in the Emergency Department and recommending low tracheostomy as the recommended form of airway management
- There is Level 2 evidence recommending CT angiogram of the neck to assess for blunt neck vascular injury
- There is Level 3 evidence recommending use of Expanded Denver Criteria for screening of patients with BNVI
Am. J of Emerg Med.
Humenansky et al. 2016.
Shaefer et al. 2014.
J of Trauma.
Gussack et al. 1988.
J Trauma EAST Guidelines.
J Trauma Acute Care surg.
Bruns et al. 2014.
DiPerna et al. 2002.
Rozycki et al. 2002.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Oct 21, 2021
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