Rosen & Barkin's 5-Minute Emergency Medicine Consult (473 page)

• Unstable patients must go directly to surgery.
  
• Laryngotracheal injuries:
  
  • Fiberoptic laryngoscopy can visualize subglottic airway, facilitate intubation, assess airway patency and injury.
    
• Esophageal injuries:
  
  • Initial study of choice: Gastrografin swallow study (less pleural irritation with extravasation) or barium swallow study
    
• Indications for endoscopy:
  
  • Odynophagia
    
  • Hematemesis or blood in saliva
    
  • SC emphysema
    

• Peripheral or CNS injury
  
• Cervical spine injury
  
• Associated head or thoracic trauma
  

TREATMENT

• Airway must be vigilantly monitored:
  
  • Edema or expanding hematoma can progress to airway compromise.
    
• Orotracheal intubation preferred 1st-line technique for airway control
  
• Clinical signs of respiratory distress:
  
  • Stridor
    
  • Air hunger
    
  • Labored breathing
    
  • Expanding neck hematoma
    
• Blind nasotracheal intubation should be avoided:
  
  • Owing to anatomy distortion and risk of hematoma rupture
    
• Cervical spine must be stabilized.
  

Airway management with cervical spine control:

• Immediate intubation indicated for patients with signs of airway compromise or impending compromise
  
• Cricothyroidotomy or emergent tracheostomy may be needed if oral intubation is unsuccessful.
  
• Contraindicated if bruising or hematoma noted over thyroid/cricoid cartilage
  
• Bleeding into pharynx can be reduced by packing throat with heavy gauze after airway is secured by intubation.
  
• Unstable patients must go directly to OR.
  

• Surgical consultation should be obtained for patients with suspicion of vascular, tracheal, or esophageal injury.
  
• Immediate surgical repair is required for symptomatic vascular injury, tracheal injury, pharyngeal, or esophageal injury.
  
• Laryngeal injury may not require immediate surgical repair.
  
• Anticoagulation is recommended for vascular injuries due to consequent luminal narrowing and thrombosis:
  
  • Results in improved neurologic outcomes
    
  • Requires surgical consultation prior to initiation of therapy
    

• Anticoagulation (see above)
  
• Prophylactic antibiotics recommended in presence of an esophageal injury to prevent abscess formation (anaerobic coverage):
  
  • Cefoxitin: 2 g (peds: 80–160 mg/kg/d div. q6h) IV q8h
    or
    
  • Clindamycin: 600–900 mg (peds: 25–40 mg/kg/d div. q6–8h) IV q8h
    or
    
  • Penicillin G: 2.4 million U/d (peds: 150,000–250,000 U/kg/d) IV q4–6h, + metronidazole
    
  • Metronidazole: 1 g load, then 500 mg (peds: 30 mg/kg/d div. q12h) IV q6h
    

FOLLOW-UP

• Patients who are symptomatic, have abnormal studies, or have significant blunt trauma mechanism must be admitted and observed for at least 24 hr.
  
• Patients with suspicion of airway or vascular injury must be admitted to ICU.
  

Only patients with most trivial injuries who have negative studies may be discharged from ED after thorough evaluation.

Patients should be given return precautions to the ED for delayed signs of vascular, tracheal, neurologic injury.

• Vascular injuries frequently have delayed presentation.
  
• Look for vascular injuries in blunt neck trauma patients with neurologic deficit and normal head CT.
  
• Always prepare for difficult airway and have specialty intervention (anesthesia, ENT) on standby (if available).
  

• Miller PR, Fabian TC, Bee TK, et al. Blunt cerebrovascular injuries: Diagnosis and treatment.
  J Trauma
  . 2001;51(2):279–285.
  
• Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: Analysis of diagnostic modalities and outcomes.
  Ann Surg
  . 2002;236(3):386–393.
  
• Rathlev NK, Medzon R, Bracken ME. Evaluation and management of neck trauma.
  Emerg Med Clin North Am
  . 2007;25(3):679–694.
  
• Ullman E. Blunt neck trauma. In: Wolfson AB, Hendey GW, Ling LJ, et al., eds.
  Harwood-Nuss’ Clinical Practice of Emergency Medicine
  . Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
  

CODES

• 900.00 Injury to carotid artery, unspecified
  
• 900.89 Injury to other specified blood vessels of head and neck
  
• 959.09 Injury of face and neck
  

BASICS

• Wound severity gauged by violation of platysma muscle
  
• Neck is divided into 3 zones
  
  • Zone I: Between clavicles and cricoid cartilage
    
    • Involves vessels, lungs, trachea, esophagus, thyroid
      
    • Penetrating trauma in this zone carries highest mortality owing to injury to thoracic structures.
      
  • Zone II: Between cricoid cartilage and angle of mandible
    
    • Involves vessels, trachea, esophagus, C-spine, and spinal cord
      
    • Injuries are most common in this zone due to it being most exposed region.
      
  • Zone III lies above angle of mandible to base of skull
    
    • Injuries are difficult to access surgically
      

Larynx is located higher in neck and receives better protection from mandible and hyoid bone.

• Gunshot wounds
  
• Stab wounds
  
• Miscellaneous (e.g., glass shards, metal fragments, animal bites)
  

DIAGNOSIS

• Vascular:
  
  • Active/persistent hemorrhage or hematoma
    
  • Pulse deficit
    
  • Horner's syndrome (carotid injury)
    
  • Vascular bruit or thrill
    
  • Venous air embolism
    
• Aerodigestive:
  
  • Respiratory distress
    
  • Stridor
    
  • Hemoptysis
    
  • Tracheal deviation
    
  • SC emphysema
    
  • Pneumothorax
    
  • Sucking wound
    
  • Hoarseness, aphonia, dysphonia
    
  • Dysphagia/odynophagia
    
• Neurologic:
  
  • Central or peripheral nervous system deficits
    

• Wounds across midline increase injury significance
  
• Stab wound
  
  • Size of instrument
    
  • Mostly low-energy penetration
    
• Gunshot wound
  
  • Type of gun used
    
  • Long range vs. close range
    

• Careful exam of wound to determine extent of injury and whether it penetrates platysma
  
• Wounds should never be probed blindly:
  
  • May result in uncontrolled hemorrhage
    

• Platysma violation
  
  • No: Wound care, discharge
    
  • Yes:
    
    • Unstable: Emergent airway, OR
      
    • Stable: Workup depends on zone violation
      

• Type and cross-match.
  
• Baseline CBC, chem panel, coags