Neck and Cervical Spine Trauma

Published on 26/03/2015 by admin

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Last modified 26/03/2015

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Chapter 59 Neck and Cervical Spine Trauma

Howard Kadish, MD

1 What are the differences in neck anatomy between children and adults?

Compared with adults, children have a larger head and mandible and a shorter neck in proportion to the rest of their body. These differences protect the child’s anterior neck at the time of injury; the head, neck, and face absorb the major force of impact. In infants and young children, the larynx is not only smaller in overall size but also has smaller relative dimensions compared with adults. In children, the arytenoids are larger, the epiglottis has an omega shape, and the larynx has a funnel shape, which is narrowest in the subglottis. In adults, the narrowest point of the trachea is located at the level of C7, whereas in children it is at the cricoid cartilage (C3). These anatomic differences, along with the ringlike cricoid cartilage, result in a narrowed laryngeal inlet. Adolescents and adults can tolerate up to 50% narrowing of the airway without obvious respiratory distress. Infants and children experience significant respiratory embarrassment with this degree of restriction.

3 How should I manage a patient with a blunt or penetrating neck injury?

The goals of management should follow trauma guidelines, with strict adherence to airway, breathing, and circulation. After the airway is assessed and breathing stabilized, control any hemorrhage and maintain good cervical spine precautions rapidly. Stabilize all penetrating objects in the neck but keep them in place until they can be removed under surgical care in the operating room. Obtain routine trauma laboratory studies, including type and cross-match of blood for packed red blood cells. Minimal radiographic evaluation includes cervical spine films and chest radiograph.

4 How should the airway and breathing be managed in a child with neck injury?

Give all patients supplemental oxygen and treat them as if they were considered to have cervical spine injury until proved otherwise. Therefore, any airway manipulation should include cervical spine stabilization. Elective endotracheal intubation is not recommended unless back-up measures, such as a surgical airway or fiberoptic intubation equipment, are available. Attempted placement of an endotracheal tube through an already injured airway may cause a small mucosal laceration to progress to complete transection. In cases of laryngotracheal separation, the transected ends of the trachea may separate by as much as 8 cm. Successful passage of an endotracheal tube across this distance is difficult and may delay or preclude airway control. Trauma to the airway also may produce a blind path and inability to pass an endotracheal tube successfully. In the unstable airway, blind nasotracheal intubation is not recommended. If orotracheal intubation needs to be performed emergently, back-up measures, such as surgical and anesthesia consultation, fiberoptic bronchoscopy, cricothyrotomy, and tracheostomy, should be available in case complications occur.

5 What are the major indications for surgical evaluation in patients with neck trauma?

Unstable vital signs

Exposed cartilage

Neurologic deficits

Airway obstruction

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