Blunt and penetrating neck trauma cause a diverse combination of injuries because of the high concentration of vascular, aerodigestive, and neurologic structures in the neck. Initial presenting signs of neck injury may be subtle or obscured by trauma to other body regions, especially in the setting of blunt trauma. Missed injuries and delays in diagnosis lead to patient morbidity and mortality.
Historical and physical examination findings of neck injury are characterized as hard or soft signs (Table 163-1), with hard signs most suggestive of significant injuries. Laryngotracheal symptoms are shown in Table 163-2. Pharyngeal and esophageal injuries may initially present with few symptoms. The presence of hematemesis, hemoptysis, dysphagia, or neck emphysema is suggestive of significant injury. Vascular injuries present with a range of symptoms. Expanding hematomas have the potential to cause airway distortion and obstruction. Focal neurologic abnormalities caused by cerebral ischemia occur in the setting of carotid artery injury. A carotid bruit or thrill is a subtle examination finding of vascular injury. Neurologic injuries result from trauma to the cervical spine, lower cranial nerves, or brachial plexus. Symptoms range from sensory complaints to quadriplegia.
Table 163-1 Signs and Symptoms of Neck Injury |Favorite Table|Download (.pdf)
Table 163-1 Signs and Symptoms of Neck Injury
Hypotension in ED
Hypotension in field
Active arterial bleeding
History of arterial bleeding
Diminished carotid pulse
Unexplained bradycardia (without central nervous system injury)
Nonexpanding large hematoma
Apical capping on chest radiograph
Hemothorax >1000 mL
Air or bubbling in wound
Vocal cord paralysis
Seventh cranial nerve injury
Table 163-2 Symptoms and Signs of Laryngotracheal Injury |Favorite Table|Download (.pdf)
Table 163-2 Symptoms and Signs of Laryngotracheal Injury
Cervical ecchymosis or hematoma
Laryngeal edema or hematoma
Restricted vocal cord mobility
Strangulation is a unique mechanism of blunt neck injury caused by hanging, ligature application, or manual neck compression. The clinical presentation of strangulation depends upon the duration and amount of force applied to the neck. Cardiac arrest, cervical spine fractures, cerebral anoxia, hyoid bone, and laryngeal injuries are possible. Increased venous pressure above the location of a ligature causes facial and conjunctival petechial hemorrhages.
The zone classification summarizes structures placed at risk for injury in penetrating neck trauma (Fig. 163-1). Zone I structures include the lung apices, thoracic vessels, distal trachea, esophagus, cervical spine, and vertebral and carotid arteries. Zone II structures include the mid carotid and vertebral arteries, jugular veins, esophagus, cervical spine, larynx, and trachea. Zone III structures include the proximal carotid and vertebral arteries, oropharynx, and cervical spine.