Blunt and Penetrating Neck Trauma

Blunt and Penetrating Neck Trauma

Eric Raschke, DO1 and Leslie Kobayashi, MD2

1 Madigan Army Medical Center, Tacoma, WA, USA

2 Division of Trauma, Acute Care Surgery, Surgical Critical Care and Burns, University of California San Diego, San Diego, CA, USA

  1. A 2‐year‐old sustains a fall from a second story window. There is significant facial trauma on the primary survey causing airway obstruction due to copious amounts of bloody secretions in the oropharynx. The patient is tachycardic and normotensive; oxygen saturation is 93% on 15 L by face mask but is difficult to mask ventilate. You have performed a jaw thrust and placed an oral airway. What is the next best step in management?

    1. Supraglottic airway
    2. Needle cricothyroidotomy
    3. Open cricothyroidotomy
    4. Open tracheostomy
    5. Nasotracheal intubation

    Airway emergencies in pediatric patients are rare but lethal situations. The first attempt to secure the airway should be performed by the most senior operator under optimal conditions and can include advanced airway adjuncts such as bougies, fiberoptic or rigid bronchoscopy, and supraglottic devices such as laryngeal mask airways (LMAs). In contrast to adults, the preferred surgical airway for small children is open emergent tracheostomy. Cricothyroidotomy is not recommended for patients under 12 years of age as this is the narrowest portion of the pediatric airway and associated rates of subglottic stenosis are high. Instead, a percutaneous catheter or needle cricothyroidotomy and jet insufflation can be used to oxygenate the patient temporarily. Ventilation is necessarily restricted, and carbon dioxide levels will predictably rise over time. Conversion to an open tracheostomy or repeated attempt at intubation with advanced airway adjuncts or more experienced personnel should be performed rapidly to prevent carbon dioxide accumulation.

    Answer: A

    Krishna SG, Bryant JF, Tobias JD. Management of the difficult airway in the pediatric patient. J Pediatr Intensive Care. 2018; 7(3): 115–125.

    Engelhardt T, Virag K, Veyckemans F, Habre W. Airway management in pediatric anaesthesia in Europe‐insight from APRICOT (Anaesthesia Practice In Children Observation Trial): a prospective multicenter observational study in 261 hospitals in Europe. British J Anaesthesia. 2018; 121(1): 66–75.

  2. A patient who contracted viral pneumonia has been intubated in the intensive care unit (ICU) for 2 weeks; they have tested positive for COVID‐19 on PCR; the patient failed initial attempt at extubation requiring immediate reintubation and now cannot be weaned from the ventilator. The decision is made to perform a tracheostomy. Which of the following maneuvers should be undertaken to decrease the risk of transmission during the procedure?

    1. Use of N‐95 mask or PAPR (powered air‐purifying respirators).
    2. Use of protective eyewear and full barrier precautions with gown and gloves.
    3. Performance of procedure in an airborne infection isolation room.
    4. Use of controlled apnea during the procedure.
    5. All of the above.

    When dealing with aerosol‐generating procedures in the face of SARS‐type infection patients, it is essential to understand which measures need to be done to reduce transmission to the healthcare team. Any interaction should be performed using standard precautions, including handwashing and barrier precautions with gown, gloves, cap, mask, and eye protection. A higher risk of transmission is present during aerosol‐generating procedures, and additional precautions should be taken. Aerosol‐producing procedures include endotracheal intubation/extubation, bronchoscopy, mini‐bronchoalveolar lavage, open suctioning of airways, manual ventilation, unintentional or intentional ventilator disconnections, bilevel positive airway pressure, continuous positive airway pressure, cardiopulmonary resuscitation, and high‐flow oxygen. In these cases, additional use of N‐95 masks and/or PAPR is recommended. In the particular case of tracheostomy placement, the use of controlled apnea during the airway maneuvers has been shown to be safe for the patient and efficacious in preventing transmission to the operating surgeon and staff.

    Answer: E

    Murphy P, Holler E, Lindroth H, et al. Short‐term outcomes for patients and providers after elective tracheostomy in COVID‐19 positive patients. J Surg Res. 2020; 260: 38–45.

    Center for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID‐19) Pandemic. 2020.

  3. A 33‐year‐old helmeted driver in a dune buggy crash is brought to the trauma bay. The patient is obtunded, requiring urgent intubation. Subsequent workup reveals a significant subdural hemorrhage and a fracture with a complete transection of the spinal cord at C3. The patient also has a flail chest on the right and hemopneumothorax. The patient is stabilized following intubation and chest tube placement, and the orthopedic spine service plans operative fixation of the spinal fracture the following day. Which of the following statements is true?

    1. Early use of high‐dose steroids will significantly improve neurological outcomes in this patient.
    2. Early rib plating will significantly improve mortality in this patient.
    3. Early tracheostomy is safe even if anterior cervical spine fixation is required.
    4. Early tracheostomy should be avoided in this patient because of the risk of cross‐contamination at the cervical spine fixation site.
    5. Percutaneous tracheostomy should be avoided because of the risk of surgical site infection after anterior spinal fixation.

    High cervical spinal cord injuries (SCI) have significant effects on patient respiratory status and carry a high risk of developing respiratory failure. Early tracheostomy has been shown to decrease hospital and ICU length of stay, reduce sedation requirements, and lower rates of pneumonia and hospital costs. In this clinical scenario, not only does the patient have a high cervical SCI, there is also a concomitant flail chest wall injury, making short‐term ventilator liberation unlikely. Early tracheostomy is recommended in these patients, and there has not been any associated increase in hardware infection rates with anterior approach cervical spine fixation or cross‐contamination of surgical sites using either open or percutaneous approaches. While early rib plating may improve times to ventilator liberation, it has not been shown to reduce mortality. Additionally, the location of this patient’s injury makes rib plating less impactful on time to ventilator liberation. While there are randomized controlled trials that demonstrate a modest improvement in ASIA grade with steroid administration following blunt SCI, more recent evidence to support their use is lacking and risks of infectious and metabolic complications likely outweigh the potential benefit for most patients, particularly those with complete injury.

    Answer: C

    Lozano CP, Chen KA, Marks JA, et al. Safety of early tracheostomy in trauma patients after anterior spinal fusion. J Trauma Acute Care Surg. 2018; 85(4): 741–746.

    Kaczmarek C, Aach M, Hoffmann MF, et al. Early percutaneous dilational tracheostomy does not lead to an increased risk of surgical site infection following anterior spinal surgery. J Trauma Acute Care Surg. 2017; 82(2): 383–386.

  4. A 27‐year‐old restrained driver involved in a high‐speed motor vehicle collision with rollover and significant passenger space intrusion presents to the emergency department (ED) reporting loss of consciousness and amnesia to the events following the accident. The primary survey is intact; the secondary survey demonstrates no external signs of injury. What diagnostic tests should be performed?

    1. CT scan of the head only
    2. CT scan of the head and cervical spine
    3. CT scan of the head, cervical spine and CT angiogram of the neck
    4. CT angiogram only
    5. CT scan of the cervical spine only

    This patient has several risk factors for a head injury, spinal injury, and blunt cerebrovascular injury (BCVI). Adjuncts to the secondary survey should evaluate for intracranial hemorrhage, spinal fracture, and BCVI. BCVI is present in up to 5% of blunt trauma admissions and can be devastating, associated with severe disability and even death. Early identification and treatment are paramount in modern trauma systems to reduce stroke risk and prevent poor outcomes associated with such injuries. CT angiography with multichannel (16–64) detectors has become the most commonly utilized screening modality. Screening criteria for BCVI have been a topic of evolution; however, the adoption of increasingly liberal criteria has been favored in many studies in an attempt to capture missed injuries. Commonly utilized screening criteria including the Denver criteria, Eastern Association for the Surgery of Trauma, Western Trauma Association, and the Scandinavian Neurotrauma Committee Guidelines have been associated with sensitivities as low as 57–84%, and missed injury rates of 20% including Denver grade 3 or higher injuries. While universal screening remains controversial, liberal criteria including screening for the mechanism of injury alone should be advocated to reduce the risk of missing significant injuries.

    Answer: C

    Muther M, Sporns PB, Hanning U, et al. Diagnostic accuracy of different clinical screening criteria for blunt cerebrovascular injuries compared with the liberal state of the art computed tomography angiography in major trauma. J Trauma Acute Care Surg. 2020; 88(6): 789–795.

    Leichtle SW, Banerjee D, Schrader R, et al. Blunt cerebrovascular injury: The case for universal screening. J Trauma Acute Care Surg. 2020; 89 (5): 880–886.

    Geddes AE, Burlew CC, Wagenaar A E, et al. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg. 2016; 212(6): 1167–1174.

  5. A 19‐year‐old marine was in a training exercise and fell from a 20 foot wall. Immediately after the fall, he reports that he cannot move his legs and only shrugs his shoulders. Glasgow Coma Scale (GCS) is 15. The primary survey is intact; on the secondary survey, you confirm there is no motor function in the bilateral lower extremities, and the patient can only shoulder shrug in the bilateral upper extremities. The patient is currently respiring comfortably on 2 L nasal cannula and can speak in full sentences. Workup confirms cervical spine fracture with associated spinal cord injury. The patient is admitted to the ICU for observation while awaiting spinal decompression and fixation by Neurosurgery. Which of the following factors predict the need for intubation and mechanical ventilation?

    1. Decreasing vital capacity
    2. Young age
    3. Lower cervical spine (C5 and below) injury level
    4. Ability to cough
    5. GCS 15

    Cervical spinal cord injuries (SCI) have a high rate of morbidity and mortality from respiratory complications. Of hospitalized patients with cervical SCI, 4 out of 5 deaths are from pulmonary dysfunction and pneumonia. The phrenic nerve that innervates the diaphragm arises from the C3–C5 nerve roots; therefore, the injury’s location plays a large role in the degree of pulmonary dysfunction, with higher injuries being associated with higher risks of respiratory complications. The diaphragm is responsible for generating approximately 65% of the normal respiratory tidal volume, with the remaining 35% attributed to the accessory muscles. Intact accessory muscle function and strong cough are associated with lower rates of respiratory complications. During the first 7 days post‐injury, the patient should have frequent measurements of vital capacity (VC), and intubation should be considered with a decreasing VC or VC approaching < 10 mL/kg, which signifies fatigue and pending respiratory failure. Altered mental status with GCS ≤ 13, older age, and comorbid conditions also increase the risk of overall complications, respiratory complications, and death.

    Answer: A

    Berlly M and Shem K. Respiratory management during the first five days after spinal cord injury. J Spinal Cord Med. 2007; 30 : 309–318.

    Claxton AR, Wong DT, Chung F, Fehlings MG. Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury. Can J Anaesth. 1998; 45(2): 144–149.

  6. A patient is brought into the trauma bay, the patient’s eyes remain shut, there is no verbal response, and they exhibit extension with deep stimulation. Based on GCS, you decide to intubate for airway protection. Several attempts at endotracheal intubation via direct laryngoscopy have failed. What is the next step in airway management?

    1. Emergent cricothyroidotomy
    2. Percutaneous tracheostomy
    3. Open tracheostomy
    4. Blind nasotracheal intubation
    5. Extracorporeal membrane oxygenation

    This situation’s goal is to not reach the point of “cannot intubate, cannot oxygenate” (CICO). Hypoxic brain injury occurs between 4 and 6 minutes of apnea and is irreversible after about 6 minutes. Studies have shown that hypoxemia in brain injury patients can significantly worsen the neurologic outcome. The first attempt to secure the airway should be for definitive tracheal access via direct laryngoscopy. Maneuvers to improve success at endotracheal intubation include appropriate positioning in patients without cervical spine precautions, use of video laryngoscopes, and use of a bougie. Attempts at tracheal intubation should be limited to 3–4 passes and should be halted immediately if any significant desaturations occur. Repeated attempts, even with experienced personnel, are associated with worse outcomes. Definitive surgical airway should be the next step in management; this is with a cricothyroidotomy in adults. Tracheostomy both open and percutaneous methods should only be utilized in controlled situations with a secure airway and are not emergent airway options in adult trauma patients.

    Answer: A

    Frerk, C, Mitchell, VS, McNarry, AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J. Anaesth. 2015; 115 (6): 827–848.

    Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018; 120(2): 323–352.

  7. A 26‐year‐old polytrauma patient has been ventilator‐dependent in the ICU for 7 days. The presence of traumatic brain injury and respiratory failure make long‐term mechanical ventilation likely. Multiple studies have demonstrated the benefits of early tracheostomy. Regarding methods of tracheostomy placement, which of the following is correct?

    1. Percutaneous tracheostomy is more expensive than open.
    2. Mortality and bleeding rates are similar between open and percutaneous tracheostomy.
    3. Percutaneous tracheostomy has higher rates of surgical site infection compared to open.
    4. Technical difficulties are less likely in percutaneous compared to open tracheostomy.
    5. Operative time is generally longer during percutaneous compared to open tracheostomy.

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Blunt and Penetrating Neck Trauma

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