{"id":5408,"date":"2011-07-14T20:26:17","date_gmt":"2011-07-14T20:26:17","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5408.htm\/"},"modified":"2013-11-24T14:45:54","modified_gmt":"2013-11-24T19:45:54","slug":"neck-trauma","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/system\/neck-trauma.htm\/","title":{"rendered":"Neck Trauma"},"content":{"rendered":"

<\/span>Western Trauma Association Penetrating Neck Trauma Guidelines 2013<\/span><\/h2>\n

\"wta-neck-trauma-2013\"<\/a><\/p>\n

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(Journal of Trauma and Acute Care Surgery Issue: Volume 75(6), December 2013, p 936\u2013940)<\/p>\n

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\"\"<\/a> from Emerg Med Austalasia<\/p>\n

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Vascular Injuries, Pharyngoesophageal injuries, or\u00a0 Laryngotracheal injuries.<\/p>\n

Anterior=forward to sternocleidomastoid<\/p>\n

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Zone I-below cricoid, angio\/esophogram\/endoscopy\/bronchoscopy<\/p>\n

Zone II-between cricoid and mandible.\u00a0 Go to OR<\/p>\n

Zone III-above mandible, angio\/esophogram\/endoscopy\/bronchoscopy<\/p>\n

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\"\"<\/a>\"\"<\/a>\"\"<\/a>\"\"<\/a>\"\"<\/a>\"\"<\/a><\/p>\n

If platysma is violated, requires surgical evaluation<\/p>\n

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Look for Horner’s syndrome (Ptosis, miosis, anhydrosis,<\/p>\n

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“whooshing” in the ears (pulsatile tinnitus), which is associated with carotid dissection.\u00a0 Pain on swallowing<\/p>\n

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Esophageal evaluation usually consists of gastrograffin swallow (less pulmonary sequelae than barium), followed by barium, and then endoscopy.<\/p>\n

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Carducci et al., characteristics of patients requiring immediate exploration include: shock, active bleeding, hematoma (moderate size or expanding), pulse deficit, bruit, neurological deficit, dyspnea, hoarseness, stridor, dysphonia, hemoptysis, subcutaneous emphysema, dysphagia, or hematemasis<\/p>\n

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can swing the injured external to damaged interna and sacrifice distal external carotid<\/p>\n

if patient is stable, consider angiogram<\/p>\n

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posterior neck wounds<\/p>\n

if possible, perform angiogram; there is no easy way to operatively intervene on vertebral injuries<\/p>\n

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pretracheal fascia is in continuity with the mediastinum<\/p>\n

look at articles by Demetriades<\/p>\n

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Insert foley to tamponade GSW bleeding<\/p>\n

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Have patient cough, swallow, and speak<\/p>\n

mandatory exploration was derived from high velocity injuries during WWII<\/p>\n

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Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use<\/p>\n

of helical computed tomographic angiography. J Trauma 2005;58:<\/p>\n

413-418.<\/p>\n

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This article echoes the results of the preceding one. It reviews the<\/p>\n

authors’ current protocol for managing penetrating neck injuries, with<\/p>\n

specific evaluation of the use of helical CT angiography. The technique<\/p>\n

used was administration of nonionic contrast delivered at a rate of 3 to<\/p>\n

4.5 mL\/s to a total administered volume of 100 mL. Three-dimensional<\/p>\n

volume-rendered images were then recreated, which gave the surgeon an<\/p>\n

excellent perspective of any lesion viewed from multiple lines of sight. The<\/p>\n

authors found that helical CT angiography was 100% sensitive, 98%<\/p>\n

specific, and had a predictive value of 93%.<\/p>\n

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<\/span>Zone II Clinical Guidelines<\/span><\/h2>\n

Level I: Selective operative management and mandatory<\/p>\n

exploration of penetrating injuries to zone II of the<\/p>\n

neck have equivalent diagnostic accuracy. Therefore,<\/p>\n

selective management is recommended to minimize<\/p>\n

unnecessary operations.<\/p>\n

Level II: High resolution CT angiography offers appropriate<\/p>\n

diagnostic accuracy with minimal risk, making this<\/p>\n

the initial diagnostic study of choice when available.<\/p>\n

Level III: No recommendations.<\/p>\n

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Diagnosis of Arterial Injury<\/p>\n

Recommendations<\/p>\n

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Level I: No recommendations.<\/p>\n

Level II: CT angiography or duplex US can be used in<\/p>\n

lieu of arteriography to rule out an arterial injury in<\/p>\n

penetrating injuries to zone II of the neck.<\/p>\n

Level III: CT of the neck (even without CT angiography)<\/p>\n

can be used to rule out a significant vascular injury if<\/p>\n

it demonstrates that the trajectory of the penetrating<\/p>\n

object is remote from vital structures. With injuries in<\/p>\n

proximity to vascular structures, minor vascular<\/p>\n

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Diagnosis of Esophageal Injury<\/p>\n

Recommendations<\/p>\n

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Level I: No recommendations.<\/p>\n

Level II: Either contrast esophagography or esophagoscopy<\/p>\n

can be used to rule out an esophageal perforation<\/p>\n

that requires operative repair. Diagnostic workup<\/p>\n

should be expeditious because morbidity increases if<\/p>\n

repair is delayed by more than 24 hours.<\/p>\n

Level III: No recommendations.<\/p>\n

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Value of the Physical Examination<\/p>\n

Recommendations<\/p>\n

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Level I: No recommendations.<\/p>\n

Level II: No recommendations.<\/p>\n

Level III: Careful physical examination using protocols<\/p>\n

for serial examinations, including auscultation of the<\/p>\n

carotid arteries, is 95% sensitive for detecting arterial<\/p>\n

and aerodigestive tract injuries that require repair.<\/p>\n

Given the potential morbidity of missed injuries, clinicians<\/p>\n

should have a low threshold for obtaining<\/p>\n

imaging studies.<\/p>\n

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J Trauma. <\/em>2008;64:1392\u00961405.<\/p>\n

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<\/span>Strangulation Injuries<\/span><\/h2>\n

The literature does not provide specific recommendations as to how to evaluate such patients, in part because presentations are so variable, and because discussions of such injuries often lump hangings and manual strangulation together. It is clear, however, that the severity of traumatic forces that result in significant injury may not be evident on initial examination (1,2,3). Emergency physicians must take seriously any patient who reports a history of recent strangulation injury.<\/p>\n

Tardieu Spots and result from the rise in venous pressure in response to the strangulation or ligature tightening.<\/p>\n

When a patient presents to the ED in significant distress or with signs and symptoms suggesting a specific injury, the management is often obvious. A standard evaluation algorithm for the patient who is asymptomatic, however, does not exist. Suggested studies for patients that have been strangled include the following: Soft-tissue neck x-rays should be ordered in nearly all strangulation patients. They may demonstrate subcutaneous emphysema (e.g. because of a fractured larynx), fracture of the hyoid bone, or tracheal deviation because of edema or hematoma. CT scan of neck structures. MR of the soft tissues of neck. In addition, gadolinium-enhanced MR angiography can rapidly image the carotid arteries from the aortic arch to the circle of Willis, making it particularly applicable in the setting of blunt cervical injuries where the level of injury is unknown (2). Carotid doppler ultrasound. Duplex evaluation is being used increasingly as a screening tool in patients with blunt neck trauma, although angiography remains the gold standard for diagnosing blunt carotid artery injury (2). There are anecdotal reports using helical CT scans to demonstrate blunt carotid artery injuries, but future studies are needed to validate its efficacy. Laryngosocopy. Vocal cord and tracheal evaluation, especially in patients with dyspnea, dysphonia\/hoarseness, odynophagia Precisely how the array of available studies are to be used and which patients warrant an extensive work-up if they are without signs and symptoms is not clear. Since specific protocols are lacking, it might be illuminating to note how a minimally symptomatic strangulation victim was managed in actual practice at a level 1 trauma center. The patient depicted on the preceding page underwent soft tissue films of the neck, CT imaging of his larynx and MRA to evaluate for possible carotid injury. All of the studies were negative and he was discharged home. He had no delayed injuries noted in follow-up examination. One interesting point: Behavioral changes in patients who have been strangled are important to note, but are often dismissed as a psychological in origin given the stress of the attack. Behavioral changes may manifest early as restlessness and combativeness because of temporary anoxia and subsequently resolve. Victims have been reported to die days or even several weeks later because of progressive, irreversible encephalopathy (1). References: (1) McClane GE, et al. A Review of 300 Attempted Strangulation Cases, Part II: Clinical Evaluation of the Surviving Victim J Emerg Med 2001; 21: 311-315 (2) Kumar SR Cervical vascular injuries: carotid and jugular venous injuries Surg Clin North Am 2001; 81: 1331-44 (3) Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th Edition, Copyright 2002 Mosby, Inc.<\/p>\n

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