Managing blunt & penetrating neck trauma in the field
You_re called to a report of a man assaulted. On arrival, you find a 42-year-old male with a severe open neck wound. The patient was apparently attacked, and a bystander found him walking down the road with uncontrolled bleeding from a stab wound to the neck. The patient is unconscious with agonal breathing. Oral intubation attempts are unsuccessful. You ventilate the patient with a BVM, continuing ventilation en route to the hospital.
On arrival to the emergency department (ED), an ED physician performs oral intubation. But when the patient is ventilated, air and blood spray from the knife wound in the neck (see photo). It_s quickly determined that the wound is a severe tracheal injury.
The ED physician then manipulates the endotracheal tube into the distal portion of the trachea, just past the suspected tracheal transection. During this part of the resuscitation, the rest of the standard trauma arrest protocol is accomplished, including bilateral chest tubes, femoral lines and blood administration after 2 L of crystalloid and code medications. The patient is resuscitated to a point of ˙reasonably stableÓ vital signs and is sent for operative intervention.
Neck injuries can be some of the most overwhelming and dramatic scenarios you_ll see during your career. These injuries often involve airway concerns, potential spinal cord injuries and large amounts of blood loss from external wounds. All neck injury patients should be taken seriously, and rapid transport to the closest appropriate facility should be facilitated. The care provided in the field is often what separates a patient who survives from one who dies. To provide this level of care, we must understand the anatomy of the region and how to do a clinical assessment of the neck after both penetrating and blunt injuries.
The neck is bounded by the skull base superiorly and the thoracic inlet inferiorly, and it contains numerous vital structures in a relatively small area. Posteriorly, the central nervous system passes through the neck along the protected course of the spinal column.
The hypopharynx and esophagus are situated in front of the spinal column, separated by a potential space (prevertebral space) that communicates with the superior mediastinum. This can be a potential area for the spread of blood or air from the neck into the chest).
The course of the arterial vessels begins at the base of the neck with the aortic arch and its branches. At the thyroid and hypopharynx, the common carotid arteries (CCA) divide into the internal and external carotid arteries. The internal jugular vein (IJV) is anterior and lateral to the CCA and is found just underneath the sternocleidomastoid muscle (SCM).
The aerodigestive structures are medial to the vessels. The thyroid cartilage is an easily identified surface marker for the larynx, with the cricothyroid cartilage positioned just below and attached by the cricothyroid membrane. The trachea begins below the epiglottis at the level of the fifth cervical vertebra and is intimately joined posteriorly to the esophagus. Thus, posterior tracheal wounds are often associated with concomitant anterior esophageal injury.
Using a system that divides the neck into zones will define anatomic regions of injury that correlate with diagnostic and therapeutic algorithms specific to those areas. The most common classification system divides the neck into three zones anterior to the lateral border of the SCM (see Figure, below). Zone I: From the thoracic outlet to the cricoid cartilage. Zone II: From the cricoid to the angle of the mandible. Zone III: From the angle of the mandible to the base of the skull. Often, providing adequate direct pressure in hemodynamically unstable patients may mandate your continued "assistance" until the patient is in the OR and the surgeon has vascular control.
Neck injuries are unique because they can cause problems with airway, breathing and circulation at the same time. Initial priorities include controlling hemorrhage and establishing a secure airway. Many patients with neck injuries will require an emergent airway procedure; thus rapid assessment is paramount.[2,3]
Immediate control of hemorrhage is best accomplished by direct digital control from a provider donning universal precautions. Digital control should be placed in the area of the vessel injury, which may be far from the surface wound that allows blood to exit. Simply plugging the surface wound will not slow bleeding and will cause an expansion of the hematoma over the area of vessel injury. The exact area of vessel bleeding is, therefore, not always obvious, and the provider should attempt pressure in different areas until the bleeding seems to minimize.
If pressure is effective and hemodynamically significant bleeding results when direct pressure is released, prehospital providers may be asked to continue their involvement long after arrival at a trauma center. Personnel who have obtained digital control can be scrubbed into the operative field, continuing to hold pressure until operative control is obtained.
Because expanding hematomas and soft tissue swelling make endotracheal intubation more difficult as minutes go by after an injury, the most experienced provider should attempt advanced airway control first. If available, providers should employ rapid sequence intubation (RSI) that uses cricoid pressure, liberal suctioning, and a combination of sedatives and paralytics to afford the best opportunity of success on the first pass.
In some cases, an endotracheal tube will not pass secondary to laryngeal and tracheal deviation from a neck hematoma. Endotracheal tube or tracheostomy tube placement should be confirmed with an end-tidal CO2 device and auscultated lung sounds.
If possible, perform a brief neurological exam (i.e., Glasgow Coma Scale, moving hands/feet) before sedation and paralysis. Hemiplegia may herald inadequate collateral cerebral blood flow and may greatly influence the operative decision making.
If endotracheal intubation fails or you_re not certified in intubation, a host of other salvage techniques are available and should be used as local protocols dictate. Even in most cases of severe injuries, ventilation and oxygenation can be accomplished by well-performed basic maneuvers, such as positioning, liberal suctioning, administration of oxygen and assisting with the BVM if necessary. Remember that some patients with severe neck injuries will be able to protect their own airway only if positioned to sit at 90_. This should be allowed, and forcing these patients to lie flat may do more harm than good.
Once the airway is secure, quickly assess the patient_s ability to be ventilated. Every neck wound should be thought of as a potential chest wound, with possible pneumothorax, hemothorax or both, depending on the wounding agent and trajectory. The chest exam should include visual inspection for injury, auscultation of breath sounds, palpation for subcutaneous air and crepitus, and evaluation for equal chest rise.
If any problems are identified, be ready to take corrective action. Be prepared to perform needle decompression and possibly a chest tube, if within your protocol. Assess for ease of ventilation with a BVM, lung sounds, EtCO2, and SpO2 before and after all procedures. Document your findings as soon as possible.
In many cases, neck wounds are accompanied by other injuries. To avoid missing other injuries, move quickly to the secondary survey, performing it in a head-to-toe fashion. Inspect every inch, hole and crevice of the patient_s body. Fully expose the patient to check for wounds covered by clothing. Undergarments should be removed as well and may provide you with useful information about the types of injuries. For example, rectal bleeding may indicate a bowel injury, and wounds from knives or bullets may be identified. Any additional injuries revealed during the secondary survey should be addressed only after hemorrhage control and a secure airway have been established.
It_s an early winter morning, and local skiers are going crazy. Your crew has already flown four patients from the same ski area. At 3 a.m., the house alarm goes off: ˙ALS Medic 1ƒRespond with BLS. Ski area. Head injury.Ó As you reach the ski area, the helicopter is on final approach for the pad at the bottom of the mountain and the patient is at the top with the BLS unit. Per witnesses, the patient was riding an inner tube down a Double Black Diamond ski slope, lost control, hit a snowmaking pole and was thrown into a tree and down a 10-foot embankment.
You arrive to find the BLS providers ready to move the patient, who is completely unconscious. You observe a copious amount of blood from the patient_s nose, ears and mouth. Multiple facial fractures are noted on palpation, and the airway is not intact. The patient_s neck is already swollen, and you_re concerned the airway will be increasingly compromised. The crew is suctioning vigorously, and your partner radios down the mountain to the flight team to ready the cricothyrotomy kit.
You attempt intubation, but nothing is visible, even with constant suctioning. The swollen neck makes landmarks impossible to identify. An oral airway is placed; the patient is ventilated via BVM and transported to the helipad. The patient is loaded on the aircraft and taken to the local trauma center.
From motor vehicle crashes (MVCs) to a closed fist, the mechanisms of blunt trauma can vary greatly. It_s not always easy to identify blunt trauma, but the effects to the neck and spine can have significant consequences. These types of injuries are usually identified by multiple assessments.
First is the assessment of the mechanism of action. What caused the injury? Was the patient thrown from a vehicle after hitting a pole at a high rate of speed, or was the patient kicked by a horse? Where was the impact and from what direction did it come? This is where we as prehospital providers have to search deeper into the scenario. Look at the direction of the car, points of impact, destruction. Ask the patients if they remember being struck and how it happened. Look for witnesses to the incident to ask if they can shed light on the subject.
With blunt injury, the concern for spinal cord injury is high. Other concerns include blunt fractures of the larynx and trachea, along with blunt cerebrovascular injuries to the carotid arteries.
Management of penetrating neck injury requires decisive and accurate actions to prevent rapid deterioration. In this case, airway and hemorrhage control are not simply part of the primary survey; rather, they represent but a few of the potential injuries to the many vital anatomic structures in this relatively small space.
Approximately 20Ï25% of patients with penetrating neck injuries will require an emergent airway procedure. Rapid assessment and early intubation is essential because expanding hematomas and soft tissue swelling can make endotracheal intubation more difficult within minutes. Again, perform a neurological exam before sedation and paralysis. One of your highest skilled providers should be at the head of the patient, ready to apply a rescue technique, such as cricothyrotomy, if endotracheal intubation fails. A surgical airway is rarely necessary but should be performed without hesitation once the decision has been made. Fluid resuscitation should be limited to that required to maintain a systolic blood pressure of 90 mmHg or a palpable radial pulse.[2,3] Hard signs (i.e., active bleeding, expanding hematomas and stridor) mandate immediate transport to the closest trauma center.
Injuries to the larynx and trachea are uncommon but have significantly high morbidity and mortality rates. Patients often present with obvious signs of airway injury, such as stridor, dyspnea or subcutaneous crepitus. Airway control is again paramount and should be performed by the most experienced of providers or a combination of providers supporting each other.
The endotracheal approach to intubation has been shown to be safe in selected patients with this type of injury.[2,3] It allows for controlled placement and direct visualization of airway structures. Again, these are devastating injuries and require expeditious intervention for optimal outcomes.
Evaluation of the vascular system in the neck begins with a rapid search for the ˙hard signsÓ of vascular injury, including pulsatile bleeding, expanding hematomas and bruits (i.e., the sound of blood passing an obstruction or stenosis). Patients with these hard signs require immediate operative care.
Once hard signs have been excluded, vascular assessment proceeds with an examination for any neurologic deficits. Neurological deficits, such as hemiplegia or unilateral cranial nerve deficit, are soft signs of carotid injury and may also need exploration. Therefore, patients experiencing any of these ˙hardÓ or ˙softÓ signs should be expeditiously transported to the nearest trauma center.
With blunt trauma injuries, we tend to think along the lines of cervical spine and spinal cord injury. However, recent data shows that we greatly underestimate the incidence of cerebrovascular (carotid and/or vertebral) injuries, in the field and in the hospital setting. Vascular injury can be deadly; decreased or absent blood flow can be devastating.
Patients can present hours after the traumatic insult with neurological compromise. Stroke-like symptoms are a strong identifier of traumatic vascular injury of the neck. Many large blood vessels in the neck feed the brain, and any disruptionƒwhether complete or incompleteƒcan cause serious harm and lasting deficits. Assessment is again the key to an accurate diagnosis. Thus, assessments must be thorough and provided to the awaiting hospital staff in a concise and complete manner.
Spine Injuries & Immobilization
Spinal immobilization has become second nature in the field. Anyone suspected of having a cervical spine injury (blunt or penetrating) is treated with cervical spine immobilization to prevent further injury. However, recent data suggests that cervical spine injuries related to penetrating trauma are not commonly associated with unstable spinal cord injuries; those that are unstable are usually significant (and complete) cord injuries when immobilization wouldn_t make a difference.
Further, immobilization may place the patient at a higher risk for missed life-threatening injuries. Uncontrolled bleeding, expanding hematomas, tracheal deviation and subcutaneous emphysema can be hidden by the cervical collar. Recently, it has been demonstrated that almost one out of four patients with neck injury will have one or more of these signs present; these signs will be overlooked with collar immobilization.[2,3,5] Additionally, unnecessarily immobilizing the patient will make endotracheal intubation significantly more difficult.
Returning to the opening case scenario, the patient was found to have suffered a tracheal transection just below the cricothyroid membrane, with a tear down the right bronchus. He survived his initial insult but suffered an anoxic brain injury secondary to the long periods of hypoventilation and hypoxia during the initial resuscitation.
The patient in the second scenario was found to have multiple cervical spine fractures, along with a fractured and crushed larynx and completely disrupted trachea. Endotracheal intubation also failed at the trauma center, and surgeons performed an emergency cricothyrotomy.
In critical cases of penetrating and blunt neck trauma, such as the ones described, prehospital care often sets the course for patient outcomes. Thus, EMS providers must have a solid understanding of involved anatomy and maintain sharp clinical assessment skills. Airway compromise, severe blood loss and spinal cord injuries must be appropriately addressedƒconsidering risks of any interventionƒin order to successfully manage these patients and prevent rapid deterioration during transport. Beyond any field interventions, your patient assessment is the key to an accurate diagnosis and definitive care.
Todd M. Burda, RN, BSN, CEN, EMT-P, is a flight nurse with Vanderbilt Life Flight at the Vanderbilt University Medical Center in Nashville, Tenn.
Bryan A. Cotton, MD, FACS, is an assistant professor in the Department of Surgery in the Division of Trauma & Emergency Surgery, Surgical Critical Care at the Vanderbilt University Medical Center. He is also the director of Surgical Critical Care at the Middle Tennessee VA Medical Center in Nashville. Contact him firstname.lastname@example.org.
- American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors: Student Course Manual, 7th edition. American College of Surgeons: Chicago, 2004.
- Cotton BA, Pryor JP: ˙Neck injuries.Ó In: Mahoney PF, Ryan JM, Brooks AJ (Eds), et al: Ballistic Trauma: A Practical Guide, 2nd edition. Springer-Verlag: London, 2005.
- Maxwell RA: ˙Penetrating neck injury.Ó In: Peitzman AB, Rhodes M, Schwab CW, et al: The Trauma Manual, 2nd edition. Lippincott Williams & Wilkins: Philadelphia, 2002.
- Biffl WL, Moore EE, Offner PJ, et al: ˙Blunt carotid and vertebral arterial injuries.Ó World Journal of Surgery. 25(8):1036-1043, 2001.
- Barkana Y, Stein M, Scope A, et al: ˙Prehospital stabilization of the cervical spine for penetrating injuries of the neck: Is it necessary?Ó Injury. 31(5):305-309, 2000.