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 ED^1,2 .
• 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:

1. 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).

2. What was the strength of force applied? (low, medium, high).
3. What structures were directly under the impact of the force?
4. Was the force isolated, sustained, or repetitive?
5. 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 scan^3,4,5,6.
    • 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 airway^4,5,6.
      • 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 intubation^4,5,6:
      • • 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.

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 neck^7,8
  • 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 LOC^7,9,10.

• 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

1. Management of Laryngotracheal Trauma
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2. External laryngotracheal trauma: Incidence, airway control, and outcomes in a large Canadian center

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3. Am. J of Emerg Med.
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4. The Laryngoscope.
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5. J of Trauma.
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   28:1439-1444.

   
   

6.  J Trauma EAST Guidelines.
   2010.
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7.  J Trauma Acute Care surg.
   Bruns et al. 2014.
   76(3).

   
   

8. Am Surg.
   DiPerna et al. 2002.
   68:441-445.

   
   

9. J Trauma.
   Rozycki et al. 2002.
   52: 618-623.