Neck Trauma: Diagnosis and Management in the Emergency Department - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

Traumatic neck injuries can affect many vital structures and have a risk for occult or delayed presentations, including stroke. This issue presents evidence-based guidelines for the diagnosis and treatment of neck trauma and discusses management controversies. You will learn:

How a thorough understanding of the structures at risk in each anatomical zone of the neck informs the differential

The current evidence and guidelines regarding cervical spine immobilization in both the prehospital and ED settings

Why and how to apply the “no zone” approach to management of neck trauma

How to make imaging decisions in patients with either penetrating or blunt neck trauma

Guidelines for identifying patients who may be at risk for blunt cerebrovascular injury, even in the absence of symptoms

The management consideration for patients with strangulation injuries

Hemorrhage control options in neck trauma

The special considerations for neck trauma in elderly patients with fall injuries

1. Abstract
2. Case Presentations
3. Introduction
4. Anatomy and Pathophysiology
5. Prehospital Care
6. Emergency Department Evaluation
   1. Primary Survey
   2. Secondary Survey
7. Diagnostic Studies
   1. The “No Zone” Approach
   2. Penetrating Neck Trauma
   3. Blunt Neck Trauma
      1. Whiplash Injury
   4. Strangulation
8. Treatment
   1. Penetrating Neck Trauma
   2. Blunt Neck Trauma
   3. Strangulation
9. Special Populations
   1. Female Patients
   2. Pediatric Patients
   3. Geriatric Patients With Fall Injuries
10. Controversies and Cutting Edge
    1. Cervical Spine Immobilization
    2. Clinical Decision Rules
11. Disposition
12. Summary
13. Time- and Cost-Effective Strategies for Neck Trauma Management
14. Case Conclusions
15. Clinical Pathway for Emergency Department Management of Neck Trauma
16. Tables and Figures
    1. Table 1. Zones and Structures of the Neck
    2. Table 2. Hard and Soft Signs of Neck Injury
    3. Table 3. Clinical Findings for Significant Neck Injury
    4. Table 4. Clinical Decision Rules for Clearing the Cervical Spine Without Imaging
    5. Table 5. Risk Factors for Cervical Spine Injury in Children With Blunt Trauma
    6. Figure 1. Classification of Anatomical Zones of the Neck
    7. Figure 2. Cervical Seatbelt Sign
    8. Figure 3. Algorithm for Diagnosis and Management of Blunt Cerebrovascular Injuries in Adults
17. References

Abstract

Neck trauma is an uncommon but serious presenting complaint in the emergency department. Many vital structures may be affected in a patient with a traumatic neck injury, including the airway, digestive tract, and carotid and vertebral arteries. Emergency clinicians must also be prepared to diagnose and manage occult and delayed presentations of injury related to neck trauma. This supplement reviews advances and best practices in the evaluation and management of patients with neck trauma, with a focus on evidencebased guidelines. A streamlined algorithm is provided as well as discussion of recent changes and controversies in neck trauma management in the prehospital and emergency department settings.

Case Presentations

A 16-year-old boy who was a restrained passenger in a motor vehicle crash is brought into the trauma bay by EMS…

• The patient is tachycardic and tachypneic, and there are visible contusions and subcutaneous emphysema around a small, palpable defect near the patient’s sternal notch.
• You request a surgical consult and order initial lab tests and imaging. As you proceed with the first steps in resuscitation, you consider the hard and soft signs of neck injury that may be found on physical examination…

A 33-year-old woman presents to the ED with multiple small stab wounds on her neck following a domestic violence incident…

• The patient is otherwise healthy and well appearing.
• She is hemodynamically stable with no signs of respiratory distress.
• You ask yourself: should this patient go directly to the operating room, or should you order imaging studies first?

EMS arrives from the local prison with a 61-year-old man after a prison officer found him hanging by his neck from a rope in his cell…

• The patient is conscious but confused. There are visible rope marks around his neck.
• What are the appropriate next steps in diagnosing and treating this patient with a near-hanging strangulation injury?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Emergency Department Management of Neck Trauma

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Tables and Figures

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random­ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the ref­erence, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

1. Al-Thani H, El-Menyar A, Mathew S, et al. Patterns and outcomes of traumatic neck injuries: a population-based observational study. J Emerg Trauma Shock. 2015;8(3):154-158. (Retrospective analysis; 51 patients)

2. * Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018;100(1):6-11. (Literature review) DOI: 10.1308/rcsann.2017.0191

3. Schaider J, Bailitz J. Neck trauma: don’t put your neck on the line. Emerg Med Pract. 2003;5(7):1-28. (Review)

4. * Irish JC, Hekkenberg R, Gullane PJ, et al. Penetrating and blunt neck trauma: 10-year review of a Canadian experience. Can J Surg. 1997;40(1):33-38. (Retrospective case series; 85 patients) 

11. * Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68(2):471-477. (Guidelines) DOI: 10.1097/TA.0b013e3181cb43da

13. Wong K. Guideline review: EAST blunt cerebrovascular injury. Accessed April 1, 2021. (Guideline review)

14. * Larson S, Delnat AU, Moore J. The use of clinical cervical spine clearance in trauma patients: a literature review. J Emerg Nurs. 2018;44(4):368-374. (Systematic literature review) DOI: 10.1016/j.jen.2017.10.013

15. * Sundstrøm T, Asbjørnsen H, Habiba S, et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014;31(6):531-540. (Review) DOI: 10.1089/neu.2013.3094

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Keywords: neck trauma, neck injury, c-spine injury, cervical spine injury, penetrating neck trauma, blunt neck trauma, blunt cerebrovascular injury, BCVI, strangulation, hanging, near hanging, whiplash, esophageal injury, laryngotracheal injury, platysma, no zone approach, cervical spine immobilization, cervical collar, hard signs, soft signs, seatbelt sign, Canadian C-Spine Rule, NEXUS Criteria for C-Spine Imaging, CTA neck, neck hyperextension, central cord syndrome