Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Blunt and penetrating neck trauma

  •    

    Key Points

    1. A patient with an apparently stable airway, in the first few hours, may deteriorate quickly due to oedema.  Even minor signs should still lead to very careful observation.
    2. All patients with a neck injury who require intubation should be considered to have a difficult airway.  Immediate assistance from anaesthetic and ENT specialists is strongly recommended.

    Background

    Traumatic neck injuries are rare in children due to their comparatively short necks, and the relative protection afforded by the mandible and cervical spine.  However, the neck contains a number of vital structures, that if injured can rapidly lead to a loss of life. 

    Neck trauma may be blunt, penetrating or a combination of both. Penetrating neck injuries in the older child may include those from gunshot wounds, stab wounds, or debris, such as glass or shrapnel, secondary to experimentation with flammable/explosive materials.  Younger children may sustain penetrating injuries after falls onto objects in their environment (e.g. twigs, fence posts) or held in their mouth (e.g. toothbrushes) or hands (e.g. pencils, chopsticks).  Blunt injuries tend to be secondary to motor vehicle accidents, especially if unrestrained, or motorcyclists (clothes-line or garrotting type injuries).  Blunt injuries to the neck may also occur due to non-accidental injury (strangulation) or hanging.

    Patients with neck trauma have commonly been involved in a multi-system trauma requiring initial assessment following an ATLS protocol.

    During the assessment of the neck, consider the four types of vital structure in the neck.

    1. Airway – consists of pharynx, larynx, trachea and lungs
    2. Vascular structures
      •  Arteries - carotid arteries, vertebral arteries, brachiocephalic artery
      • Veins - jugular and subclavian veins
      • Nerves – Spinal cord, Brachial plexus, cranial nerves, peripheral nerves
      • Gastrointestinal tract – Pharynx, oesophagus

      Blunt injuries - Assessment

      Features on history – any direct blow/trauma to the neck or severe blow to head/face

      • Eliciting the exact nature of the injury, and the regions of the body injured can be difficult as the injury may be unwitnessed or “hidden” within the multi-trauma patient
      • Blunt injuries to the neck can lead to laryngeal injury and airway compromise, vascular injury with resultant stroke, neurological injury to the brachial plexus or spinal cord (see C-spine CPG)

       

      Mechanism Examples
      Falls
      • toddlers falling and striking neck onto the edge of a low table
      • older children falling from bicycles and striking neck on the handle-bars
      Quad bike or motorbike injuries
      • ‘clothes-line’ (garrotting) type injury in either setting
      MVA
      • rapid deceleration of restrained passenger, especially with sash of seatbelt lying across the neck
      • rapid deceleration of unrestrained passenger hitting neck onto dashboard
      • other hyperextension or hyperflexion injury
      Sports injury
      • hit in neck with cricket ball
      • elbowed in neck during football game
      • martial arts strike to neck
      Strangulation / assault
      • Hanging, ligatures around neck, suffocation, choking
      • direct blow or kick to neck

         

      Features on examination:

      1. Aero-digestive signs/symptoms include:
        • Bruising / wound to neck
        • Dyspnoea / stridor
        • Dysponia / hoarseness / aphonia
          • Dysphagia / odynophagia
          • Laryngeal tendernes
          • Cervical crepitus / surgical emphysema
            • Haemoptysis

          • Vascular signs / symptoms include:
            • Expanding haematoma to neck
            • Bruits / thrills in carotid artery
            • Seat-belt mark to neck
            • Sensorimotor deficits
            • Cerebellar symptoms
            • Visual symptoms
            • Vomiting
            • Loss of consciousness
            • Massive epistaxis
            • Horner's syndrome / anisocoria

          • Neurological signs / symptoms
            • abnormal neurological examination of limbs

          A patient with an apparently stable airway, in the first few hours, may deteriorate quickly due to oedema.  Even minor signs should still lead to very careful observation.

          Management

          Investigations:

          Plain chest XR - may show pneumomediastinum / pleural effusion / hydrothorax / subcutaneous emphysema in the event of oesophageal perforation

          Plain X-rays of neck (soft tissue views) - May show surgical emphysema and soft tissue swelling, but are unreliable in demonstrating laryngeal injury.

          CT angiogram of neck - Evidence the role of CT angiogram of the neck to screen for associated cerebrovascular injury to carotid and/or vertebral arteries is limited in the paediatric population.

          Indications for CT angiogram of neck in blunt trauma include:

          • Lateralising neurologic deficit (not explained by CT head)
          • Infarct on CT head
          • Cervical haematoma
          • Massive epistaxis
          • Anisocoria / horner's syndrome
          • GCS <8 without significant CT head findings 
          • Cervical spine fracture
          • Base of skull fracture - in particular a fracture extending through the petrous temporal bone and involving the carotid canal
          • Severe facial fracture (LeForte II or III only)
          • Seatbelt sign above the clavicle

          NB: A plain CT neck, i.e. without contrast, may be better able to identify laryngeal fracture, but should not be performed in the unstable patient

          Contrast swallow

          • ENT may advise a contrast study, but this investigation should not be ordered without ENT consultation
          • Water soluble contrast, if swallowed prior to x-ray may reveal a contrast leak
          • Barium contrast can cause mediastinal and/or pulmonary inflammation if aspirated so it is better avoided if there is an aspiration risk.

          All patients with signs / symptoms of injury to the neck should be discussed with ENT for consideration of fibreoptic laryngoscopy.

          Acute Management

          Initial assessment of patient along EMST guidelines

          IF airway stable:

            • Assess for signs/symptoms of aero-digestive injury - presence of any warrants discussion with ENT for consideration of flexible fibreoptic laryngoscopy.  Dyspnoea, dysphonia and stridor are red flags.
            • Assess for signs/symptoms of vascular injury - high risk mechanisms are often associated with polytrauma - if concerns discuss with radiology / vascular surgeons the utility of CT angiogram of neck.

            IF unstable airway injury:

            • Apply basic airway management techniques whilst summoning help
            • Apply 100% O2 via high flow non-rebreather mask
            • Perform jaw thrust to open upper airway
            • Consider gentle mask ventilation (avoid aggressive positive pressure ventilation – which can worsen cervical emphysema and compromise adequate ventilation
            • Any patient with an altered conscious state will require a definitive airway and ventilation HOWEVER:
              • All patients with a neck injury who require intubation should be considered to have a difficult airway - Immediate assistance from anaesthetic and ENT specialists is strongly recommended
              • Be aware that the administration of paralytics to a patient with a laryngeal injury may lead to complete airway obstruction – if at all possible awake fibreoptic guided intubation or rigid bronchoscopy in the operating theatre is preferred to attempted intubation in ED.
              • If emergent intubation is required outside of the operating theatre – for example in the peri-arrest patient with acute hypoxia then the following should be considered:
                • Smaller than anticipated ETT sizes may be required - due to swelling.  Attempted intubation of partially injured trachea risks worsening the injury and potentially converting a partially transected trachea into a complete transection.
                • A surgical airway kit must be available an the clinician prepared to use it if orotracheal intubation fails.
                • Use of a video device if available.
                • Consider the possibility of an unstable cervical spine fracture in neck trauma.  Be aware of neck position during emergent intubation.

            Management of blunt neck injury

              Flowchart outlining treatment of blunt neck injury        

            Penetrating injuries

            Historically penetrating injuries to the neck have been considered along the lines of anatomical location, with all injuries in Zone II (between cricoid and angle of the mandible) requiring surgical exploration, and those in Zone I (clavicles to cricoid) and III (angle of mandible to base of skull) requiring imaging.

            Practical management of penetrating neck injury can be considered along looking for hard or soft signs of injury (see below)

            Penetrating Injuries - Assessment

            Features on History

            • Penetrating injuries may be low velocity (e.g. stabbing) or high velocity (e.g. gunshot, explosive debris)
            • Actively look for injuries elsewhere – patients who have been stabbed / shot may have multiple wounds.  Patients involved in a blast injury will commonly have multiple injuries.

            Features on examination

            • Look for hard / soft signs of vascular and aerodigestive injury[1]

             

              Hard signs Soft signs
            Vascular
            • Active bleeding
            • Large (expanding) haematoma
            • Bruit / thrill
            • Reduced GCS
            • Shock
            • Minor bleeding
            • Small haematoma
             
            Aerodigestive
            • Haemoptysis
            • Haematemesis
            • Air / Bubbles in wound
            • Dysphagia
            • Dysphonia
            • Subcutaneous air

               

            In paediatrics it is prudent to consider stridor as an additional "hard" sign as it may indicate impeding airway loss secondary to bleeding into the airway, or from swelling encroaching on the patency of the airway.

            Acute Management:

            • Patients with Hard signs require operative management - Intubation in the operating theatre is preferred to attempted intubation in ED
            • Patients with Soft signs (if stable) require a CT angiogram
            • Patients with No signs can be observed

            All wounds deep to the platysma,  should be discussed with the ENT team.

            Severe vascular injury may require consultation between the On Call Paediatric Surgeon, the Cardiac Surgery Consultant, the Plastic Surgery Consultant, the RCH Interventional Radiologist and/or with the On Call RMH Vascular Surgeon as per the following policy:  Severe Vascular Injury in Children

            Referral

            Consider consultation with local ENT team:

            All injuries with signs of blunt or penetrating neck trauma should be discussed with ENT

            Consider transfer when:

            All children with major trauma, including blunt / penetrating neck trauma, should have definitive management in the major trauma centre (RCH)

            Children requiring care beyond the comfort level of the hospital

            For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.  PIPER will in turn arrange consultation with the RCH Emergency Deartment and ENT teams, in addition to others relevant to planned transfer.

            References

            1. Sperry et al.  (2013) Western Trauma Association Critical Decisions in Trauma: Penetrating neck trauma.  J Trauma Acute Care Surg 2013;75(6):936-940