Pediatric emergency medicine trisk 3575 3575
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Approximately 85% of patients with blunt tracheal injury reportedly have
subcutaneous emphysema, although the onset may be delayed ( Fig. 112.9 ).
However, airway injuries may be subtle and not apparent with initial history or
physical examination but progress to severe abnormalities such as airway
obstruction from tracheal edema as late as 48 to 72 hours after the injury.
The esophagus is mobile and is usually collapsed as it courses through the neck
but may be dilated while eating. This mobility helps protect the esophagus, but its
delicate mucosal walls can be damaged easily by blunt traumatic events.
Iatrogenic esophageal injuries can result from endoscopy, passage of a nasogastric
or orogastric tube, vigorous suctioning, and difficult intubations. Esophageal
injuries can also be seen with ingested foreign bodies and caustic chemicals. The
injuries, which can be subtle, occult, and difficult to diagnose, can lead to
increased morbidity and mortality if not identified.
Isolated or concurrent hyoid bone injuries are also possible, but rare. The hyoid
is mobile and fairly well protected, which explains the paucity of isolated injury.
As with other injuries, these symptoms and signs can be subtle initially, with
progressive edema and airway obstruction.
Vascular injuries are also rare with blunt trauma. These injuries are often
unsuspected and undiagnosed on routine examination. Risk factors for injury have
been reported to include Glasgow Coma Scale (GCS) score of less than 8; head
injury; basilar skull fracture; and facial, neck, thorax, or abdominal injury. The
cervical seatbelt sign, bruising, and/or abrasions in the distribution of the seat belt
along the neck are not predictive of cerebrovascular injury. The most common
vascular structure injured with blunt trauma is the common carotid artery. The
vertebral arteries are rarely injured by blunt forces unless a concurrent transverse
process or other cervical spine fracture occurs. Atlantooccipital dislocation can
also be associated with vertebral artery injury, which if occurs frequently leads to
early death in the field. Vascular contusions with intimal damage may also be seen
with blunt neck trauma.
The glandular structures in the neck, including the thyroid, parathyroid, parotid,
and submandibular glands, may also be injured. While these organs may be
traumatized, they are rarely completely destroyed.
Clinical Considerations
Clinical Recognition
In the presence of blunt neck trauma, the triad of dyspnea, stridor, and hemoptysis
suggests laryngeal injury. Injuries above the glottis often demonstrate cervical
emphysema, dysphagia, hoarseness, and progressive airway obstruction, whereas
