Neck Trauma Lec
Neck Trauma Lec
Neck Trauma Lec
TRAUMA
APOLONIO L. LASALA, MD
Professor
Department of Surgery
Faculty of Medicine and Surgery
University of Santo Tomas
Background
• Few emergencies pose as great a challenge
as neck trauma
• Neck is a relatively small conduit where
multitude of organ systems are involved
– Respiratory/airway (eg. trachea)
– Gastrointestinal (eg. esophagus)
– Neurological (eg. cervical nerve roots,
cervical spine, brachial plexus, etc.)
– Vascular (eg. Carotid arteries, jugular
veins, great vessels, etc.)
– Musculoskeletal structures
Background
• Single penetrating wound may be harmful
or lethal
• Therefore, a clear understanding of the
anatomic relationships within the neck and
the mechanisms of injury is critical to
devising a rational diagnostic and
therapeutic strategy
Anatomy of the Neck
Anatomy of the Neck
Anatomic Structures at
Risk
• Neck protected by the spine posteriorly,
the head superiorly, and the chest
inferiorly
• Therefore, anterior and lateral regions
are most exposed to injury, esp. trachea
and larynx
• Spinal cord lies posteriorly, cushioned
by the vertebral bodies, muscles, and
ligaments, therefore, more prone for
blunt than penetrating injury
• Esophagus and the major blood vessels
are between the airway and spine
Anatomic Structures at
Risk
• Musculoskeletal: • Neural structures:
– cervical spine – spinal cord
– cervical muscles – phrenic nerve
– tendons, and – brachial plexus
ligaments
– clavicles – recurrent
laryngeal nerve
– first and second
ribs – cranial nerves
– hyoid bone (specifically IX-
XII)
– stellate
ganglion.
Anatomic Structures at
Risk
• Vascular structures • Visceral structures:
– carotid – thoracic duct
(common, – esophagus
internal, – pharynx
external)
– larynx
– vertebral
– trachea
arteries
– brachiocephalic
– jugular (internal
and external)
veins
Anatomic Structures at
Risk
• Glandular structures:
– thyroid glands
– parathyroid glands
– submandibular glands
– parotid glands
Anatomic Landmarks
Anatomic Zones of the
Neck
Anatomic Zones of the
Neck
• Zone I
• Structures: Great vessels, trachea,
esophagus
• Involvement may have high mortality
rate upto 12%
• Osseous shield makes surgical
exploration of the root of the neck
difficult
• R side median sternotomy
• L side L anterior thora-
Anatomic Zones of the
Neck
• Zone II
• Structures: internal & external carotid
arteries, jugular veins, pharynx, larynx,
esophagus, RLN, spinal cord, trachea,
thyroid and parathyoids
• Most frequently involved (60 to 75%)
Anatomic Zones of the
Neck
• Zone III
• Structures: carotid and vertebral
arteries, jugular veins, cranial nerves
• Protected by skeletal structures and
is difficult to explore
• Recognizing injuries to the cranial
nerves exiting the base of the skull in
zone III is important because these
injuries may be indicative of injuries
• to the great vessels due to
• their close proximity
Neck trauma: Zone I
• Between clavicle
/cricoid cartilage
• Thoracic outlet –
hemothorax
• Stable patients
– CXR
– angiography
– esophagography/
endoscopy
– bronchoscopy
• Unstable patients
– immediate
exploration
Neck trauma: Zone II
• Between cricoid
/mandibular angle
• neck proper -
easiest evaluation
• wound exploration
– platysmal
penetration
• stable
asymptomatic
patients
– Observed
– Cervical spine x-ray
• symptomatic
patients
– explored
Neck trauma: Zone III
• Above angle of
mandible
• require
carotid/vertebral
angiograms
• neurologic injuries
Mechanisms of Injury
• Penetrating
• >95% results from stab and GSW
• GSW sustain more injury than stab wounds
for it damages even outside the tract
• After GSW to the neck, surgery is indicated
in 75% of cases
• About 50% of stab wound to the neck would
require surgery
Mechanisms of Injury
• Penetrating
• internal jugular vein 9% most
common sites of vascular
• carotid artery 7% injuries
• pharynx 5-15%
• esophagus
• larynx 4-12%
• trachea
• major nerve injury 3-8%
Whiplash injury
WHIPLASH INJURY
• Neck sprain or neck strain
• An injury to the soft tissues of the neck
• Often the result of rear-end car crashes
WHIPLASH INJURY
• Symptoms of Whiplash
• Neck stiffness
• Injuries to the muscles and ligaments (myofascial
injuries)
• Headache and dizziness (symptoms of a
concussion)
• Difficulty swallowing and chewing and hoarseness
• Abnormal sensation such as burning or prickling
• Shoulder and back pain
WHIPLASH INJURY
• Diagnosis of Whiplash
• Physical exam to evaluate patient’s condition
• Neurological exam
• X-ray cervical spine to rule out cervical injuries
• CT scan to assess condition of the
• cervical spine’s soft tissues
• MRI
WHIPLASH INJURY
• Treatment
• Soft cervical collar to be worn 2 to 3 wks
• Heat therapy to relieve muscle tension and pain
• Pain medications (Analgesics and NSAIDS)
• Muscle relaxants
• Range of motion of exercises and physical
therapy
• Cervical traction
Mechanisms of Injury
• Blunt
• Usually from motor vehicle accident
• Other causes:
– sports-related injuries
– strangulation
– blows from the fists or feet
Mechanisms of Injury
• BLUNT • PENETRATING
• direct blows • stab
• fall – knife/icepick
• frontal impact – sharps
• “whiplash” • gunshot wounds
• “clothesline” – small caliber
• “head banging” – rifle/shotgun
• chiropractic
• soccer
Signs/Symptoms of Neck
Injury
Shock Dyspnea Hemoptysis Focal /
Lateralized
deficit
Active Stridor Dysphagia
Bleeding
Subcutaneous Subcutaneous
emphysema emphysema
Vascular
Vascular Airway
Airway Esophagus
Esophagus Neurologic
Neurologic
Work-ups and Diagnostic
Modalities
• Mainly based on the zone
affected:
CBC, blood typing
Chest X-ray
Cervical spine X-ray (AP-lateral-
open mouth views)
Angiography
Esophagography/endoscopy
Bronchoscopy
Carotid/vertebral angiograms
CT scan
Chest X-ray
Cervical Spine X-ray