Penetrating and blunt neck traumas require rapid assessment and stabilization of the airway. For penetrating injuries, multidetector CT angiography is often sufficient to diagnose injuries requiring intervention, such as vascular injuries occurring in 4% of cases. While the "three zone" approach historically guided management, selective exploration based on imaging findings is now preferred. Blunt injuries rarely cause vascular or aerodigestive trauma but can cause delayed airway obstruction. Strangulation injuries involve neck vessel occlusion and may cause laryngotracheal or cervical spine fractures.

1. NECK TRAUMA
Dr. Haitham Sulaiman Habtar
MD , SBEM PGY-2

2. OUTLINES
2
Penetrating neck trauma
Blunt neck trauma
Strangulation

3. PATHOPHYSIOLOGY
With stab wounds, tissue
damage does not extend
beyond that which had direct
contact with the blade.
reconstruction of the tract of
the blade is usually more
difficult as compared with
reconstruction of the tract of a
gunshot wound
3

4. PATHOPHYSIOLOGY
 Low-velocity gunshot wounds (most civilian
injuries) can produce significant injury to any
structure along the direct tract of the missile,
as well as injury due to any bullet
fragmentation. The external wounds often
appear deceptively minor even in the presence
of major life-threatening injuries to deeper
structures.
4

5. PATHOPHYSIOLOGY
High-velocity gunshot
wounds (usually military-type
weapons) typically result in much
more extensive injury to
structures in the direct tract of
the missile, and can also injure
adjacent structures due to the
stretch/cavitation effect of the
missile. External wounds are
often also significantly larger.
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6. HOW TO DEAL WITH NECK TRAUMA IN ED ??
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8. AIRWAY
 Airway patency is the principal concern in patients with penetrating neck trauma.
 Oxygen should be applied immediately upon arrival, and rapid adjunct maneuvers such as head
tilt, jaw thrust, or nasal/oral pharyngeal airways should be applied. If these maneuvers fail to
achieve airway patency, plans for emergency endotracheal intubation should be coordinated
with the surgical team.
 Anticipate a difficult airway in these patients, even if there are no other traditional indicators of
potentially difficult intubation. Primary and bail-out modalities should be readily available (video
laryngoscopy, elastic bougie, fiberoptic bronchoscopy, etc.) before proceeding with rapid
sequence intubation.
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9. AIRWAY
• When the patient is alert and/or maintaining their own airway, a discussion should be held
between emergency physicians, anesthetists, and surgeons to determine the most suitable
setting for intubation.
• The OR offers superior lighting and instrumentation should a surgical airway prove necessary,
and may allow the operative team to proceed directly to a tracheostomy, if necessary, rather than
a temporary, emergency cricothyroidotomy.
• The benefits of the OR setting, however, come with the risk of losing the airway en route and
creating an emergency situation in the worst of all settings.
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10. AIRWAY
 Definitive airway priority can be organized into three categories for penetrating neck
trauma:
• Emergency: The airway is either obstructed or the patient is moving insufficient air
for adequate oxygenation/ventilation.
• Semi-emergency: The airway is patent and the patient demonstrates adequate
oxygenation and ventilation, but airway security, over time, is questionable based on
the injury pattern.
• Elective: The airway is both patent and secure, although definitive control of the
airway may be required for procedural sedation/analgesia depending on the injury
pattern.
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11. AIRWAY
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12. AIRWAY
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14. CERVICAL SPINE IMMOBILIZATION ??
Cervical spine immobilization is associated with an increased mortality rate in penetrating neck trauma and is no longer
recommended by Prehospital Trauma Life Support.
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15. BLEEDING ??
Attempts to control large
volume hemorrhage should be
made in sequence until
successful,
first with regional compression,
followed by directed digital
compression through the
traumatic wound or wound
packing,
and as a last resort with balloon
tamponade using a Foley
catheter with a 15-cc balloon
instilled with up to 20cc saline or
sterile water or to the point
where increased resistance is
felt.
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16. 16
Blindly probing a wound that is
not exhibiting exsanguinating and
pulsatile hemorrhage is
discouraged, since it could disrupt
a fixed clot, exacerbate bleeding,
or cause further injury.

17. DIAGNOSTIC CONSIDERATIONS
17

18. THREE ZONE VS NO ZONE STRATEGY
 Present management trends favor the “No Zone” strategy , based on the improvements
in diagnostic accuracy of multi-detector CT scanners, the high proportion of negative
neck explorations on routine exams, and the lack of correlation between the zone of
neck penetration and the site of internal injury.
 A selective “No Zone” strategy for penetrating neck trauma reduces the use of
arteriography by 50% and endoscopy by 90%, with no detriment to patient outcomes
as compared with the “Three Zone”.
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19. 19

20. THREE ZONE
textbooks advocated a “Three
Zone” approach to penetrating
neck trauma. Such an
algorithm was based on the
sensitivity and specificity of
traditional radiographic and
endoscopic diagnostic
modalities in diagnosing
traumatic injuries that required
intervention, the implications
of delays in diagnosing these
injuries, and the relative
accessibility of each zone by
surgical exploration.
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21. THREE ZONE
all zone II injuries were surgically
explored. This aggressive
practice began during World
War II as a response to a high
incidence of missed injuries and
mortality, but selective
management is generally
recommended today to
minimize unnecessary surgery.
Zone II is the most commonly
injured area and is easily
accessed surgically. Exposure
and vascular control are more
difficult for zone I and III injures,
so most patients with zone I and
III injuries undergo angiography
and endoscopy to determine
the need for operative
intervention 21

22. DIAGNOSTIC CONSIDERATIONS IN VASCULAR INJURIES
 MDCTA has up to 100% sensitivity for diagnosing vascular injuries requiring surgical or
endovascular intervention and is now favored by most institutions over resource-intensive
digital subtraction angiography. MDCTA identifies vascular injury in approximately 4% of
patients with neither hard nor soft signs on physical exam; however, it is rare for such clinically
occult injuries to require surgical exploration or intervention.
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23. DIAGNOSTIC CONSIDERATIONS IN AERODIGESTIVE INJURIES
• Further imaging to identify an aerodigestive injury is only required if there is some sign
of injury on exam or suspicion based on the initial MDCTA study.
 Direct visualization techniques, including pharyngoscopy, laryngoscopy, and
bronchoscopy, are preferred for the identification of injuries to the oropharynx or
larynx/trachea/bronchi
 For possible esophageal injuries, options include rigid esophagoscopy, flexible
esophagoscopy, or oral contrast imaging studies (esophageal swallow study or CT
with oral contrast). The current publication recommends a contrast swallow study
(fluoroscopy) followed by post-swallow CT to maximize diagnostic yield.
Esophagoscopy is typically reserved for intraoperative diagnostic assessment
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24. MULTIDETECTOR CT SCANNER (MDCT)
 It is extraordinarily uncommon for a
multidetector CT scanner (MDCT) to miss an
injury requiring intervention in penetrating
neck trauma, demonstrating a negative
predictive value of 98%-100%
 MDCT findings can be compromised by
suboptimal contrast timing as well as artifacts
from metallic foreign bodies such as dental
fillings, bullet fragments, and spinal hardware
in up to 1% of studies.
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25. LABORATORY EVALUATION
 Serial hemoglobin/hematocrit
 Coagulation studies
 (ABG/VBG)
 Blood type and crossmatch
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26. BLUNT NECK TRAUMA
26

27.  Blunt neck trauma composes only 5% of traumatic injuries to the neck. Road traffic accidents are the
most common cause of blunt neck trauma.
 vascular injury occurs in approximately 1% of patients with blunt neck trauma, cervical aerodigestive
injuries are rare.
 The mortality rate of symptomatic blunt cerebral vascular injury approaches 60%. 31 However, most
patients with blunt cerebral vascular injury are initially asymptomatic and do not develop neurologic
symptoms for hours to days.
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29. DIAGNOSIS
Digital subtraction angiography
is the gold standard for the
diagnosis of blunt cerebral
vascular injury.
Due to the lack of digital
subtraction angiography
availability use MDCTA as the
initial screening modality.
US has a low sensitivity for
blunt cerebral vascular injury
and should not be used as a
screening test.
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31. LARYNGOTRACHEAL INJURIES
 Penetrating neck trauma causes laryngotracheal injury in 2% to
5% of penetrating trauma patients and has a 2% to 15%
mortality rate.
 Blunt laryngotracheal injuries occur in less than 0.5% of blunt
trauma patients.
 The majority of blunt laryngotracheal trauma is caused by car
collisions.
 Patients with laryngotracheal injuries due to blunt trauma may
have a quiescent phase with progressively increasing
subclinical airway edema or hematoma that can result in
delayed airway obstruction.
 Significant laryngotracheal injuries should be detected by
physical exam.
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32. 32
Hard Soft

33. DIAGNOSIS
to define airway patency
and the extent of
intraluminal injury.
CT imaging is critical in
patients with suspected
laryngotracheal injury
without airway
compromise
33

34. 34
Grade I and II can be managed medically Grade III and above managed surgically

35. PHARYNGOESOPHAGEAL
INJURIES
Pharyngoesophageal injuries are exceedingly rare in
patients with blunt neck trauma.
typically have more subtle signs, resulting in
diagnostic delays.
Deaths from esophageal injury are usually due to
mediastinitis and sepsis
esophageal injury in patients with a history of a
sudden acceleration or deceleration event in which
the neck was extended.
injuries occur as the esophagus is forced against the
spine. 35

36. DIAGNOSIS
there are no hard signs of
pharyngoesophageal injury.
36
soft

37. 37

38. DIAGNOSIS
evaluated by either direct
esophagoscopy or swallowing
studies.
Esophagoscopy is more
sensitive for detecting
esophageal injuries with the
added benefit of quantifying
the size and extent of the injury.
The combination of these two
studies achieves 100%
sensitivity for detecting these
injuries.
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39. TREATMENT
 Treat pharyngoesophageal injuries with IV antibiotics.
 Small pharyngeal perforations may be managed medically,
 whereas pharyngeal perforations larger than 2 cm and esophageal perforations require surgical repair.
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40. STRANGULATION
Strangulation is one form of
blunt neck trauma.
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41. MECHANISMS
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hanging postural strangulation ligature strangulation manual strangulation

42. CLINICAL FEATURES
 the major pathologic
mechanism is neck
vessel occlusion rather
than airway
obstruction.
 cerebral anoxia
 strangulation injuries
include laryngotracheal
fractures, cervical spine
fractures, pharyngeal
lacerations, and carotid
artery injuries.
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43. DIAGNOSIS
X-ray
Endoscopy
CT
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44. TREATMENT AND DISPOSITION
 Patient with hard signs of strangulation injury should undergo further diagnostic testing.
 Admit patients with abnormal radiologic or endoscopic imaging to the appropriate service and level of
care.
 Unconscious patients and those with progressive symptoms such as odynophagia, hoarseness,
neurologic changes, or dyspnea require aggressive airway management
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