What is Neck Trauma (Neck Injury)?
Dealing with neck injuries can be tough and sometimes, quite intimidating since the neck contains numerous vital parts. These features may cause confusion during diagnosis and treatment in emergency scenarios.
Neck Anatomy
For description purposes and best treatment approach, the neck is divided into three parts, called zones: Zone 1, Zone 2, and Zone 3. This classification is important when it comes to penetrating injuries since the zones have different anatomical, diagnostic and management implications. Using the zone system to describe injuries is generally good as it helps guide the right treatment decision. Knowing the structures of the neck and their locations is fundamental in delivering the best care.
Zone 1: This zone is between the collarbones and a ring of cartilage, known as the cricoid cartilage. It encloses important structures like the main veins and arteries, nerves controlling the arm, windpipe, food pipe, the top of the lungs, and the thoracic duct – which carries a fluid called lymph. Surgery in this area can be complicated due to the presence of the collarbone and other bony elements close to the chest opening.
Zone II: Situated between the cricoid cartilage and the angle of the jaw, this zone contains the neck’s arteries and veins, windpipe, and food pipe. Comparatively, this area is easy to examine clinically and surgically. It is also the biggest zone and where most neck injuries occur.
Zone III: This is the area from the jaw’s angle to the skull’s base. It contains certain neck arteries and the throat. As it is close to the skull’s base, this area is tough to examine physically and during surgical evaluations.
The neck is also divided into triangles. One of them – the anterior triangle contains the voice box, windpipe, throat, food pipe and key blood vessels. The other – the posterior triangle houses muscles, a nerve called the spinal accessory nerve, and the spine.
What Causes Neck Trauma (Neck Injury)?
When it comes to neck injuries, there are mainly three types to consider:
1. The first type is blunt trauma which is often the result of car accidents or sports injuries. These types of incidents can lead to delayed signs of damage to the throat, blood vessels, and the digestive system. It’s also critical to note that often hidden neck bone or spinal injuries could be present in people with neck trauma from a blunt force. Plus, the safety belts found in cars, particularly the part that crosses your chest, may lead to scrapes or cuts on the front part of your neck.
2. The second type of neck injury comes from penetrating trauma, which accounts for around 5% to 10% of all trauma injuries. This type of trauma often results from things like gunshot or stab wounds. The severity of these injuries is established by whether the platysma, a broad thin muscle just under the skin of the neck, is damaged. If this layer is damaged, the risks for serious injury amplify. So, if a injury penetrates the platysma, damage to crucial structures in the neck might happen. Stab wounds generally cause deep, but not extensive, harm because they are the result of low-energy penetration.
The third type of neck injury happens from near-strangulation or choking. In these situations, pressure is exerted on the outer neck, obstructing blood flow and leading to insufficient oxygen supply to the brain.
The area most frequently hurt in neck injuries is called zone 2, which doctors can easily access via surgery. But, for injuries in zones 1 and 3, it’s trickier for doctors to gain access and control of the blood vessels.
Risk Factors and Frequency for Neck Trauma (Neck Injury)
Penetrating neck injuries can be quite dangerous, with a death rate as high as 10%. Most of these deaths occur due to blood vessel injuries, especially those located at the base of the neck, known as zone 1. Surprisingly, injuries to the esophagus can lead to death later on and these might not be obvious right away.
It’s also important to note that, for gunshot wounds specifically, approximately half are associated with severe injuries, leading to a death rate of 10% to 15%. On the other hand, stab wounds result in serious injury in 20% to 30% of cases, with an overall death rate of 5%. Again, delayed fatalities are often due to injury to the esophagus that isn’t immediately noticeable.
- Penetrating neck injuries can lead to death in up to 10% of cases, often due to blood vessel injuries.
- Injuries at the base of the neck, called zone 1, are particularly risky.
- When – The time of the injury
- Where – The location of the injury and potential entry and exit wounds, as well as their proximity to vital body structures
- How – The object or method that caused the wound; for example, knife, gun, motor vehicle
- Events surrounding the timing of the injury – Information from emergency and law enforcement reports
- Any other existing or underlying medical conditions
- Obstruction of the airway
- Inhalation of foreign material into the lungs
- Loss of function in the vocal cords
- Tearing of the esophagus
- Severe injury to the blood vessels
- Severe type of infection which leads to tissue death
- Stroke
- Air bubbles in the bloodstream
- Collapsed lung or blood in the chest cavity
Signs and Symptoms of Neck Trauma (Neck Injury)
When evaluating a physical injury, a thorough examination is essential. Critical information about the injury should be gathered, including details about when, where, and how the injury happened. It’s also helpful to understand any events around the time of the injury, as well as any underlying health conditions the patient may have. This can help to gauge the extent of the injury and identify related injuries. Remember, isolated injuries are not common, particularly in instances of blunt trauma. Further injuries are often associated and should be looked for.
The neck area should be checked for signs of bleeding, swelling, bruising, or any changes to its natural shape. Listening for abnormal sounds from the carotid arteries and the presence of a harsh, noisy sound produced during breathing is crucial. The neck should also be examined for tenderness or trapped air under the skin. Certain findings can suggest significant injuries to the blood vessels and/or digestive system. However, be aware that symptoms may not appear immediately. If there is a hissing or bubbling sound or visible air coming out of the wound, it may indicate a windpipe (tracheal) injury. Crackling under the skin from trapped air should alert medical teams to quickly examine for injury to the airways, esophagus or the lungs.
Assessing the wound correctly to determine the injury’s extent is crucial. The base layer of the neck’s muscle (platysma) should be examined for penetration. However, avoid blindly prodding wounds as this could lead to uncontrollable bleeding. A complete neurological consultation should also be performed.
Testing for Neck Trauma (Neck Injury)
In the event of neck injuries, it’s crucial to involve a trauma team or surgeon, if available. Physical examination alone may not be enough to identify all injuries in patients with neck trauma, so it’s wise to consider additional imaging or a surgical review if necessary. Frequent check-ups are important to catch any decline in the patient’s condition or any ongoing issues. It’s also vital to carry out a thorough second survey to check for additional injuries. Diagnostic tests are typically done for stable patients who show subtle signs of injury and sometimes even for those who don’t show any symptoms initially.
Chest x-rays are usually the first port of call for anyone with significant neck trauma. Both front-on and side-on x-rays of the neck and chest are usually taken. These x-rays help to identify possible complications like blood or air collections in the chest cavity. They are especially key in patients with injuries in a certain region of the neck called zone 1.
CT angiography, which involves using x-rays to visualize blood vessels, is typically the first investigation to check for vascular injury. Because it is less invasive, it is generally chosen over other methods to define injuries to the blood vessels in the neck.
Conventional angiography involves injecting a dye into the blood vessels to make them visible on x-rays and has an extremely high sensitivity. This test is considered the “gold standard” for evaluating vascular injury. It should ideally include imaging of the carotid and vertebral arteries, the part of the carotid artery within the brain for injuries in a specific part of the neck (zone 3), and the large vessel branching from the heart and its branches for injuries in another specific part of the neck (zone 1).
Duplex ultrasonography is a test that can also be used in stable patients. It’s non-invasive and quite affordable. However, it relies heavily on the skill of the operator and might miss some non-obstructing injuries, such as tearing of the blood vessel inner lining and abnormal bulging of the blood vessel wall. Unfortunately, its effectiveness in evaluating injuries in a specific part of the neck (zone 3) is limited.
Esophagography, a test where the esophagus is visualized after swallowing a contrast material, should be carried out if there’s a suspicion of a tear in the esophagus.
Treatment Options for Neck Trauma (Neck Injury)
When someone gets hurt in the neck area, it’s very serious because the neck contains important structures within it. We need to be quick in assessing what’s wrong and taking the necessary steps to treat it. The method we use to do this follows a specific protocol called ATLS. If we think that the person might have damaged their blood vessels, windpipe, or food pipe, we immediately get a trauma specialist involved.
When treating neck injuries, the first steps are the same as any other severe injuries. We need to make sure the person can breathe, stop any heavy bleeding, treat shock, and check their vitals to see if they’re stable. Sometimes, neck injuries come with other severe injuries that need to be addressed first.
Ensuring safe breathing is a priority, especially when neck injuries are involved. We must take care to keep the neck still in case of spine injury. Airway blockage might occur with neck injuries, so we must monitor the patient closely for any changes.
Swelling, changes in normal anatomy, or blood collections in the neck or face could make the airway become blocked. This problem could worsen quickly, so it’s important to secure the airway early.
We should also check if any lungs have been punctured or filled with blood, which can happen with certain neck injuries.
To stop the bleeding in emergency settings, we just apply direct pressure to the wound. If a wound is bubbling or sucking in air, we cover it with special sticky gauze. We must avoid putting things blindly into the wound or clamping the vessels. We also avoid blocking both main neck arteries or obstructing the airway. The placement of a stomach tube through the nose should be avoided in cases of penetrating neck injuries due to risk of worsening a blood collection.
The way we treat a patient with a neck injury will depend on the location and extent of the injury, as well as their stability. The neck is divided into zones, and the zone of the injury can guide our treatment approach.
Zone 1: This zone might have no symptoms initially, but can result in significant injury. Many hospitals advocate for evaluating the main blood vessels and food pipe in these cases.
Zone 2: This zone is easier to access surgically, and complications from exploration are less likely. Treatment depends on the symptoms. If a patient with symptoms has a penetrating neck injury in this area, they should undergo neck exploration. If they don’t have symptoms, they can be either explored or watched closely.
An angiogram, a type of imaging test, may be required if the patient has ongoing bleeding or neurological symptoms. Certain symptoms might indicate damage to important neck structures.
Zone 3: Major blood vessels and nerves near the base of the skull may be injured in this zone. Many of these injuries may not show symptoms at first, but surgical intervention could be difficult. Many injuries can be managed by an interventional radiologist in the same setting as the diagnostic test.
For unstable patients with evidence of damage to the vascular or digestive tracts, further evaluation with invasive techniques is required. These patients should be taken to the operating room for definitive management.
For stable patients, the decision to explore zone 2 injuries or perform invasive interventions in zones 1 and 3 will depend on various factors.
With improved imaging techniques, the previously mandatory exploration or arteriography for certain injuries may not be necessary. However, all patients with injury to the platysma muscle should be admitted to the surgical department or observation unit for ongoing evaluation.
Blunt trauma, which accounts for up to 5% of neck injuries, most frequently causes neck injuries during car crashes where the neck hits a dashboard or steering wheel. These injuries can directly damage blood vessels or cause them to stretch and tear. These are rarely isolated injuries, so it’s key to identify and manage any associated injuries.
What else can Neck Trauma (Neck Injury) be?
If someone gets hurt in the spinal cord or experiences strangulation, they could potentially experience serious health issues. It’s important to get immediate medical attention if these situations occur.
Possible Complications When Diagnosed with Neck Trauma (Neck Injury)
There are several complications that can occur, including:
