Link To And Excerpts From Core EM’s “Episode 173.0 – Blunt Neck Trauma”

In this post I link to and excerpt from Core EM‘s Episode 173.0 – Blunt Neck Trauma, November 2019. Hosts: Audrey Bree Tse, MD and Brian Gilberti, MD.

In addition to the above please review my post Core EM’s Outstanding Minicourse on Cervical Spine Injuries. That post is simply a list of Core EM’s great resources on the subject  so that I can do a rapid review when I need to.

Here are excerpts from Episode 173.0 [Note to my readers: I recommend listening to the entire podcast and reviewing the complete show notes. I excerpt the notes simply because it helps me fix the information in my memory.]:

Show Notes


  • Blunt neck trauma comprises 5% of all neck trauma
  • Mortality due to loss of airway more so than hemorrhage


  • MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact
  • Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)
  • Direct blows: assault, sports, falls

Initial Management/Primary Survey

  • Airway
    • Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise
    • Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
    • Assume a difficult airway
  • Breathing
    • Supplemental oxygen
    • Assess for bilateral breath sounds
    • Can use bedside US to evaluate for pneumothorax or hemothorax
  • Circulation
    • Assess for open wounds, bleeding, hemorrhage
    • IV access
  • Disability
    • Maintain C-spine immobilization
    • Calculate GCS
    • Look for seatbelt sign

Types of Injuries

  • Vascular injury
    • Overview
      • Carotid arteries (internal, external, common carotid) and vertebral arteries injured
      • Mortality rate ~60% for symptomatic blunt cerebral vascular injury
    • Mechanism
      • Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation
      • Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections
    • Clinical Features
      • Most patients are asymptomatic and do not develop focal neurological deficits for days
      • if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)
      • specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)

Tintinalli 2016

  • Diagnostic Testing
    • Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)
      • <80% sensitive but 97% specific
      • Also images aerodigestive tracts and C-spine (unlike angiography)
    • Followed by Digital Subtraction Angiography (DSA) for positive results or high suspicion
      • Angiography is invasive, expensive, resource-intensive, and carries a high contrast load
  • Management
    • Antithrombotics vs. interventional repair based on BCVI grading system
    • Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology
    • All patients with blunt cerebral vascular injury will require admission

Tintinalli 2018

  • Pharyngoesophageal injury
    • See show notes for detailed instructions on evaluation.
    • Diagnostic Testing
      • Esophagography with water-soluble contrast (e.g. Gastrograffin)
      • If negative contrast esophagography, obtain flexible endoscopy (most sensitive)
        • Combination of contrast esophagography + esophagoscopy has sensitivity close to 100%
      • Swallow studies with water-soluble agent
      • MDCTA
      • Plain films of neck and chest
        • Findings such as pneumomediastinum, hydrothorax, or retropharyngeal air may suggest perforation but are not sensitive
    • Management
      • See show notes for instructions on management.
  • Laryngotracheal injury  
    • Overview
      • Occurs in >0.5% of blunt neck trauma
      • Includes hyoid fractures, thyroid/ cricoid cartilage damage, cricotracheal separation, vocal cord disruption, tracheal hematoma or transection
    • Mechanism
      • Assault, clothesline injuries, direct blunt force from MVCs compressing the larynx between a fixed object and the spine
    • Clinical Features
      • Patients are often asymptomatic at first and then develop airway edema and/or hematoma resulting in airway obstruction
      • Children are at higher risk for airway compromise due to less cartilage calcifications
    • Diagnostic Testing
      • Flexible fiberoptic laryngoscopy (FFL) to assess airway patency and extent of intraluminal injury
      • MDCTA
        • Obtain 1-mm cuts of larynx and perform multiplanar reconstructions
      • Consider POCUS to detect laryngotracheal separation
    • Plain films of neck and chest
    • Poor sensitivity for penetrating neck trauma injuries
    • Can show extraluminal air, fracture or disruption of cartilaginous (e.g. larynx) structures
    • Management
      • When securing airway, use an ETT that is one size smaller due to likelihood of airway edema
      • Conservative management (IV antibiotics, steroids, observation) vs. surgical repair
        • Grades III, IV, and V laryngotracheal injuries as defined by Schaefer and Brown’s classification system require OR

  • Cervical spine/ spinal cord injury  


  • Admit symptomatic patients to monitored setting
  • Given delayed symptoms, consider monitoring patients who are asymptomatic on arrival
    • Serial exams for worsening dyspnea, dysphonia, stridor, drooling, bruits, focal neuro deficits
    • Only discharge after ruling out airway threat, neurological deficit, vascular injury, or suicidal/ homicidal ideation
    • Monitor asymptomatic patients on home anticoagulation in ED for at least 6 hours from trauma to rule out delayed neck hematoma
  • Social work and/or psychiatry for patients in whom you suspect suicide risk or domestric violence, look for other signs of self harm


This entry was posted in Core EM. Bookmark the permalink.