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Chapter 163: Neck Injuries

Steven Go

INTRODUCTION

Neck trauma causes a diverse combination of injuries because of the high concentration of critical structures in the neck. Presenting signs of neck injury may be obvious, subtle, or obscured by trauma to other body regions. Missed injuries and delays in diagnosis lead to increased patient morbidity and mortality.

CLINICAL FEATURES

Historical and physical examination findings of vascular, laryngotracheal, or pharynoesophageal injury of the neck are characterized as hard or soft signs (Table 163-1), with 90% of patients with hard signs having an injury requiring emergent repair.

Table 163-1

Signs and Symptoms of Neck Injury

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Table 163-1

Signs and Symptoms of Neck Injury
Hard Soft
Vascular injury
Shock unresponsive to initial fluid therapy Hypotension in field
Active arterial bleeding History of arterial bleeding
Pulse deficit Nonpulsatile or nonexpanding hematoma
Pulsatile or expanding hematoma Proximity wounds
Thrill or bruit
Laryngotracheal injury
Stridor Hoarseness
Hemoptysis Neck tenderness
Dysphonia Subcutaneous emphysema
Air or bubbling in wound Cervical ecchymosis or hematoma
Airway obstruction Tracheal deviation or cartilaginous step-off
Laryngeal edema or hematoma
Restricted vocal cord mobility
Pharyngoesophageal injury
Odynophagia
Subcutaneous emphysema
Dysphagia
Hematemesis
Blood in the mouth
Saliva draining from wound
Severe neck tenderness
Prevertebral air
Transmidline trajectory

Vascular injuries are the most common cervical injury and cause of death from penetrating neck trauma. Symptoms include frank exsanguination and expanding hematomas, which may cause airway obstruction. Cervical artery injury can also cause various vascular and neurological signs and symptoms (Table 163-2).

Table 163-2

Compiled Screening Criteria for Blunt Cerebral Vascular Injury

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Table 163-2

Compiled Screening Criteria for Blunt Cerebral Vascular Injury

  • Signs and symptoms

    • Arterial hemorrhage from nose, neck, or mouth

    • Cervical bruit in patients <50 years old

    • Expanding cervical hematoma

    • Focal neurologic deficit: transient ischemic attack, hemiparesis, vertebrobasilar symptoms, Horner’s syndrome

    • Stroke on secondary CT

    • Neurologic deficit unexplained by head CT

  • Risk factors for blunt cerebral vascular injury

    • High-energy transfer mechanism and one of the following:

      • Facial fractures: Le Fort II or III fracture, mandible fracture, frontal skull fracture, orbital fracture

      • Cervical spine fracture patterns: subluxation, fractures extending into the transverse foramen, fractures of C1–C3

      • Any basilar skull fracture or occipital condyle fracture

      • Petrous bone fracture

      • Diffuse axonal injury with Glasgow Coma Scale score ≤8

      • Concurrent traumatic brain and thoracic injuries

      • Neck hanging with anoxic brain injury

      • Clothesline type injury with significant swelling, pain, or altered mental status

Laryngotracheal injuries can present with immediate signs of impending airway obstruction (Table 163-3) or have an insidious onset of airway compromise after a quiescent phase.

Table 163-3

Clinical Factors Indicating Need for Aggressive Airway Management

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Table 163-3

Clinical Factors Indicating Need for Aggressive Airway Management

  • Stridor

  • Acute respiratory distress

  • Airway ...

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