Initial Management of Neck Trauma

Primary Assessment and Stabilization

The American College of Radiology recommends early spine immobilization for any patient with suspected spinal cord injury to limit neurological deficit progression 4, 5, 6
For patients requiring intubation with suspected cervical spine injury, the American College of Radiology suggests using manual in-line stabilization with removal of the anterior part of cervical collar during intubation 4, 5, 6
The American College of Radiology recommends employing rapid sequence induction with direct laryngoscopy and gum elastic bougie without Sellick maneuver for patients with suspected cervical spine injury 6

The American College of Radiology suggests classifying patients based on clinical stability and presence of "hard signs" or "soft signs" 1, 2, 3
Hard signs requiring immediate surgical exploration include massive subcutaneous emphysema 1, 2, 3
Soft signs requiring further evaluation include minor subcutaneous emphysema and dysphagia 1, 2, 3

The American Society of Anesthesiologists recommends maintaining systolic blood pressure >110 mmHg in patients with suspected spinal cord injury to reduce mortality 6

The American College of Radiology recommends CT angiography (CTA) as the first-line imaging modality with 90-100% sensitivity and 98.6-100% specificity for vascular injuries 1, 2, 3
CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with high sensitivity (100%) and specificity (93.5-97.5%) 1, 2
Initial radiographs may be useful to identify radio-opaque foreign bodies, soft-tissue swelling, airway compromise, fractures, and subcutaneous emphysema before proceeding to CTA 1, 2, 3
CT esophagography may be performed in conjunction with CTA for suspected digestive tract injuries (sensitivity 95-100%) 1, 2

Catheter angiography is reserved for equivocal CTA findings with concerning penetrating foreign body trajectory 3
MRI is valuable for evaluating spinal cord injury, traumatic disk injury, and ligamentous injury in stable patients without metallic foreign bodies 1, 2, 3, 7
Ultrasound has limited utility in neck trauma due to overlying soft tissue injury and limited evaluation of deep structures 1, 2, 3

Stable patients should proceed with CTA regardless of injury zone 1, 2, 3
Based on CTA findings, targeted management should be implemented for specific injuries identified 1, 2, 3

Delaying surgical exploration in patients with hard signs of vascular or aerodigestive injury is a common pitfall to avoid 1, 2
Failing to maintain cervical spine immobilization during initial assessment and management is a common pitfall to avoid 4, 5, 6
Relying solely on physical examination without appropriate imaging in stable patients is a common pitfall to avoid 1, 2, 3
Neglecting to consider potential end-organ injury, particularly to the brain, when cervical vascular injury is present is a common pitfall to avoid 1, 2