I do see parallels betw taking street fight advice from an undefeated UFC fighter and workout advice from a roided-up genetic freak …
probably not the best people to learn from.
I will mention that Bas Rutten is a highly-respected teacher in the MMA community and sought by many for his teaching.
Of course, it could all be due to his popularity and not to his effectiveness, in which case caveat emptor
Sifu wrote:
Blocking blows with your head has got to be the dumbest idea I have heard in a long time. Someone posted a video of Bas Rutten up here a while back. I wouldn’t pay to learn from him, because I’ve seen him do things that I was taught not to do when I was a white belt.
[/quote]
Now you are sounding more reasonable. I don’t really follow who all the personalities are in ufc etc. But I had figured he had come from there. That’s why people are up on his jock.
As I’ve said before you can go far in ufc on merely being a tough son of a bitch. Tough is not really something you can teach. In the ring gamemanship is not the same as a real life fight.
The video of Bas that was posted up was like a beginners guide to a barroom brawl. I looked upon it as general instructions on how to be a hardass in a bar. At one point in it he snatches up a barstool to use as a weapon without ever mentioning the downside of such a move. For example when you introduce a weapon into a fight you open the possibility that it can be taken away and used against you. There are also potentialy serious legal ramifications to such a move. I know several people who have faced lawsuits and criminal charges after a fight.
That video Bas made is something that could be introduced into a court case against him even. Imagine he grabbed someone and smashed their head into a bar and killed them and got sued or charged with manslaughter. The prosecuting attorney could show the part of the tape where he says to smash someones head into a table as evidence of a cavalier attitude towards using weapons.
The legal apects of fighting is not something to be overlooked by any means. I had a teacher who had to pay over $100,000 to rebuild the face of a guy who wouldn’t accept that he was against someone he couldn’t take. I know quite a few people who have won fights decisively and ended up getting tore up in court.
That’s why when Californialaw says unless someone has been in ten street fights they don’t have anything to teach I wonder how much real experience he actually has. Because it’s just not adviseable to be fighting outside of the dojo or a ring.
The link you provided gives information on crushed tracheas from farming MACHINERY.
“Laryngotracheal injuries constitute only a small fraction of admissions in a major trauma centre. The frequency has been reported to be as low as 0.3 percent(4). However, mortality is
reported as high as 24 percent(1). Complete disruption of trachea is amongst the rarest injuries with only a few cases reported in literature(5). Seuvre (cited by Papamicheal et al(6) is credited with the first description of traumatic tracheal disruption. Direct blows are more likely to be associated with fractures of cartilaginous frame work of the larynx(7). The signs and symptoms are often subtle even in complete transections of trachea. The two ends may be held in close approximation by peritracheal connective tissue and soft tissues of the neck.”
Oh, and to your insulting of me and not my statement, I never claimed to be anything. I am just talking about the unlikely probability of crushing someone’s trachea in a fight by punching their neck.
“Laryngotracheal injuries are relatively rare following blunt trauma to the neck and chest but results in a high degree of morbidity and mortality”.
[/quote]
Supermonkey If you read what I posted from that medical journal it said that a crushed trachea has a high incidence of mortality. It lists the rarity of such an injury in relation to an accidental chest or neck injury.
It didn’t cover someone taking a deliberate swing at someones throat. As with any strike there is a sweet spot. In the case of the throat it can be very easy to hit it just right, unless they have their chin down almost all the way to their sturnum.
Believe what you want to believe. Just know this. If you get into an altercation and haul off and punch someone in the throat thinking it won’t hurt them you might get a bad surprise that lands you in jail for a long long time. If it does happen to you, don’t say you had no idea or weren’t warned.
The fact that we are arguing wether or not crushing someones throat would be fatal shows just how clueless some of you guys are. It is a generally well accepted idea. It is why hangings were a common form of execution.
It’s why submission chokes are not allowed to go directly across the windpipe, because you can easily crush it.
I am not arguing that a crushed trachea wouldn’t be fatal.
I am arguing that the extemely unlikely scenario of someone’s throat being crushed BY a punch is not even worth considering.
Your link shows that there is a high mortality rate when the injury of a crushed trachea occurs. It also shows that a crushed trachea is one of the rarest of injuries encountered in a trauma center.
“The frequency has been reported to be as low as 0.3 percent(4). However, mortality is
reported as high as 24 percent(1). Complete disruption of trachea is amongst the rarest injuries with only a few cases reported in literature(5).”
From your link.
Now I wonder how many of those were from punches to the throat?
The statistical improbability of it happening makes it something you shouldn’t worry about.
The Earth could crash into the Sun but I am not worried about it.
[quote]Sifu wrote:
The fact that we are arguing wether or not crushing someones throat would be fatal shows just how clueless some of you guys are. It is a generally well accepted idea. It is why hangings were a common form of execution. [/quote]
No one said it wouldn’t be potentially fatal. What people did say was “Yeah, right,” when you mentioned your ability to strike someone in the throat.
I’m sure you can break many boards at throat level. But street fighting is different from breaking boards or training in a dojo. That you seem to not know this tells me all I need to know.
I’m coming into this one a little late, but I think this comment is still germane:
Saying that the best way to end a fight is with Technique X or Punch Y is about as helpful as saying that the best way to end a battle is to kill the enemy’s general.
[quote]CaliforniaLaw wrote:
Sifu wrote:
The fact that we are arguing wether or not crushing someones throat would be fatal shows just how clueless some of you guys are. It is a generally well accepted idea. It is why hangings were a common form of execution.
No one said it wouldn’t be potentially fatal. What people did say was “Yeah, right,” when you mentioned your ability to strike someone in the throat.
I’m sure you can break many boards at throat level. But street fighting is different from breaking boards or training in a dojo. That you seem to not know this tells me all I need to know.[/quote]
This is typical you don’t know me or who I trained with, yet you make assumptions based upon preconcieved notions.
The fact is my teacher never had us break any boards. He said he would rather see us break someones ribs, because he felt that was actually useful. So we were encouraged to go at it when we fought in class. I’ve had several broken ribs as a result and at this point in time I need major abdominal surgery to wire two ribs back into place.
I have also broken a cartilidge rib in my throat from where I got punched. I doubt either you or supermonkey has ever been punched hard in the throat that is why you are so clueless. The throat is not a robust area, and it is not that hard to hit.
I don’t think you have ever done any hard fighting. Otherwise you wouldn’t be so adamant that it is impossible to hit anything you are aiming at in a fight. Either that or you are one of these retasked wrestlers that UFC rules favor. Which would explain why you can’t hit what you are aiming at.
A real fight isn’t some arcane secret that only you know, that is if you have ever been in one. So come down off your high horse.
Minus the guns which I never saw anyways, my last fight wasn’t much worse than anything that I have faced in the dojo and the one before that was really nothing.
IMO one on one, plans rarely work. The other guy just won’t do what you want him to do. Swing for the head, and be happy where ever the punch lands. Most don’t. Watch even pro fighter, most punches miss. Try to aim for the nose, only because it’s in the center of the head. Increases your chances of landing.
Of course, as for the eyes, I guess there is that one ufc fighter that basically made a living out of attacking them, so maybe there is something to it, LOL…
As for multiples, unless they are idiots, your likely fucked. Two people that have a plan are damn tough to beat. Example cops. Most are fat, out of shape slobs, but two of them almost alway beat one. One goes high, one low. So your on the ground one is tying us your legs, taking away your base. You can’t get any power as the other works on your arms…
[quote]
Either that or you are one of these retasked wrestlers that UFC rules favor. [/quote]
This post tells me everything I need to know.
You’re one of those strikers who can really, truly, actually beat someone who has mastered ground fighting. You just can’t prove it because it would be too dangerous.
Really, dude, this argument was settled by the Gracies over the course of dozens of years. The Gracies fought many no rules fights, and won all of them. The only reason they’re not on top now is because of archaic training. They don’t lift, they have a silly “Gracie diet,” etc. But they did fight and defeat any comers - including those with “secret” skills. But that doesn’t take away from this: Most fights end up on the ground, thus, a complete fighter must have decent ground skills.
Anyhow, you seem to be happy doing what you’re doing. Best of luck.
Rather than all the bravado and I did this and that blah blah you don’t know me and what I do, why not provide some verifiable evidence of crushed tracheas due to punches.
No one is saying that a punch to the throat can not be effective. Do you even read my posts? I try to explain each time what I am saying but you seem to gloss over the part where I ask you to provide some evidence of a crushed trachea due to punches.
Who is saying a trachea CANNOT be crushed?
PUNCH CRUSH TRACHEA? PROOF?
[quote]Sifu wrote:
I have also broken a cartilidge rib in my throat from where I got punched. I doubt either you or supermonkey has ever been punched hard in the throat that is why you are so clueless. The throat is not a robust area, and it is not that hard to hit.
Here’s a good one, learn some Judo or wrestling or some kind of stand-up oriented grappling. Learn to underhook and control the head, throw the guy down and stomp on him a bit but don’t join him there unless it’s a knee-on-belly or knee-on-back so you can GTFO if you have to.
Maybe the samurai fighting arts are old, but the concepts remain a good idea. They were soldiers who could be attacked from any angle, by one or more people from any number of weapons at any time etc. Basically, they did what they had to do and got outta there alive. Did they have a plan, really ? No.
[quote]jarvis wrote:
CaliforniaLaw wrote:
Arm bar? When did I say to use an arm bar? Of course, if you can quickly land an arm bar and breack the guy’s arm (it’s the street, so there’d be no tap outs), then how would that NOT be effective?
Quickly landing an arm bar is not a possibility in a street fight against multiple attackers. The second you take anything to the ground you will get your head kicked in.
You either stand and strike and wait for other people to break things up or run away.
The best idea in my opinion is to not go looking for trouble on your own (or at all).
p.s. an arm bar does not break the arm it dislocates the shoulder as do almost all arm submissions; kimura, americana, omoplata etc.[/quote]
Jarvis,
If you think that an arm bar does not break the arm (damage the elbow joint), then either you have never had someone put you in an arm bar, or you are training with some very poor instructors.
Also, as far as the using an arm bar against multiple opponents comment… I’d agree that in general you want to keep your mobility at a maximum and therefore grappling is often times not a good idea.
However, I think you’re only thinking of a common lying, or upward arm bar. When in reality, any time you lock the elbow, I could be considered an arm bar. This includes standing variations, some of which do not require that you go to the ground, nor do they place you in immediate danger as you suggested.
I do agree with the rest of what you said though, although, things don’t usually go as planned and it is therefore still important to train in ground fighting (if for nothing else, only to be able to get back to your feet quickly).
Supermonkey it is because of thick headed know it alls like you that T-Nation sucks as a place for disseminating information on martial arts.
When I was coming up if I was fortunate enough to have someone with over twenty years of training take the time to share some knowledge with me I would shut up and listen to what they have to say.
If you think it is so hard to hit someone in the throat try this. The next time you are with your sparring partners (Assuming you actually do train) tell them you want them to try and hit you in the throat full power. If you aren’t willing to do this then you need to STFU.
T-Nation being home to mixed martial artists. What a joke that is. It’s more like home to a bunch of ufc groupies who think they are martial arts experts because they have pay per view.
The risks posed by a blunt trauma to the trachea are well documented in the medical literature. Because I was too lazy to go dig through 61,500 google hits to find just the right article for to convince a dumbass doesn’t mean it’s not out there. I just think it is ridiculous to go digging for proof of something that is so obvious.
My knowledge of martial arts has been hard won and taken many years of studying. It has cost me a lot of money and time. I’ve come here and offered it freely and all I get is attacked by people who don’t have any martial arts background other than watching ufc on tv.
So I am through with this. Although I’m not going to post anymore to this it does not mean I am conceding the point. I’ve just had my fill of blockheads who think they know everything there is to know about martial arts because they’ve seen ufc on tv.
Blockheads who make false assumptions based upon ignorance. I’ve never told anyone this but I actually have freinds who fought in the original Gracie owned ufc. I also studied for years under a man who trained swat teams for a living. None of these people are fucking around with their training.
I have finally burned out on these retarded pissing matches.
Oh by the way here is the evidence you wanted.
Author: David Levy, DO, Medical Director, Chairman, Department of Emergency Medicine, Lancaster Regional Medical Center
David Levy, DO, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Informatics Association, and Society for Academic Emergency Medicine
Editor(s): Edmond Hooker, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville, Wright State University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Assistant Professor of Emergency Medicine, New York University Medical School; Consulting Staff, Department of Emergency Medicine, Bellevue Hospital Center, New York University Hospital, Manhattan VA Hospital; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Assistant Professor of Medicine, David Geffen UCLA School of Medicine; Director of Informatics, Department of Emergency Medicine, UCLA/Olive View-UCLA Medical Center
Background: Few emergencies pose as great a challenge as neck trauma. Because a multitude of organ systems (eg, airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound is capable of considerable harm. Furthermore, seemingly innocuous wounds may not manifest clear signs or symptoms, and potentially lethal injuries could be easily overlooked or discounted.
Airway occlusion and exsanguinating hemorrhage pose the most immediate risks to life. From the time when Ambroise Pare successfully treated a neck injury in 1552, debate has continued about the best approach for particular neck wounds. Awareness of the various presentations of neck injuries and the establishment of a well-conceived multidisciplinary plan prior to the traumatic event is critical for improving patient outcome.
Pathophysiology: A clear understanding of the anatomic relationships within the neck and the mechanisms of injury is critical to devising a rational diagnostic and therapeutic strategy.
Anatomic relationships
Structures at risk
With the neck protected by the spine posteriorly, the head superiorly, and the chest inferiorly, the anterior and lateral regions are most exposed to injury. The larynx and trachea are situated anteriorly and are, thus, readily exposed to harm. The spinal cord lies posteriorly, cushioned by the vertebral bodies, muscles, and ligaments. The esophagus and the major blood vessels are between the airway and spine.
Two fascial layers invest the neck: the superficial fascia enveloping the platysma muscle and the deep cervical fascia. A deeper cervical fascia envelops the sternocleidomastoid and trapezius muscles, as well as demarcates the pretracheal region (including the trachea, larynx, thyroid gland, and pericardium), the prevertebral area (containing the prevertebral muscles, phrenic nerve, brachial plexus, and axillary sheath), and the carotid sheath (enclosing the carotid artery, internal jugular vein, and vagus nerve).
Musculoskeletal structures at risk include the cervical spine; cervical muscles, tendons, and ligaments; clavicles; first and second ribs; and hyoid bone.
Neural structures at risk include the spinal cord, phrenic nerve, brachial plexus, recurrent laryngeal nerve, cranial nerves (specifically IX-XII), and stellate ganglion.
Vascular structures at risk include the carotid (common, internal, external) and vertebral arteries and the vertebral, brachiocephalic, and jugular (internal and external) veins.
Visceral structures at risk include the thoracic duct, esophagus and pharynx, and larynx and trachea.
Glandular structures at risk include the thyroid, parathyroid, submandibular, and parotid glands.
Associated structures at risk of intrathoracic injuries include the esophagus, tracheobronchial tree, lung, heart, and great vessels.
Anatomic zones
Dividing the neck into anatomic zones or regions assists in the evaluation of injury. Serving as the line of demarcation, the sternocleidomastoid separates the neck into anterior and posterior triangles. The majority of the important vascular and visceral organs lie within the anterior triangle bounded by the sternocleidomastoid posteriorly, the midline anteriorly, and the mandible superiorly. Except for individual nerves to specific muscles, few vital structures cross the posterior triangle, which is delineated by the sternocleidomastoid, the trapezius, and the clavicle (with the exception of the region just superior to the clavicle).
For clinical purposes, the neck is partitioned into 3 zones (see Image 1). Zone I (see Image 2), the base of the neck, is demarcated by the thoracic inlet inferiorly and the cricoid cartilage superiorly. Structures at greatest risk in this zone are the great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, and jugular veins), aortic arch, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots. Signs of a significant injury in the zone I region may be hidden from inspection in the chest or the mediastinum.
Zone II (see Image 3) encompasses the midportion of the neck and the region from the cricoid cartilage to the angle of the mandible. Important structures in this region include the carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, and cervical spine and spinal cord. Zone II injuries are likely to be the most apparent on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with Zone II injuries.
Zone III (see Image 4) characterizes the superior aspect of the neck and is bounded by the angle of the mandible and the base of the skull. Diverse structures, such as the salivary and parotid glands, esophagus, trachea, cervical spine, carotid arteries, jugular veins, and major nerves (including cranial nerves IX-XII), traverse this zone. Injuries in zone III can prove difficult to access surgically.
Mechanisms of injury
Neck trauma may be caused by penetrating or blunt trauma.
Penetrating trauma
More than 95% of penetrating neck wounds result from guns and knives, with the remainder resulting from motor vehicle accidents, household injuries, industrial accidents, and sporting events. Penetrating trauma includes gun shot wounds (GSWs) and stab wounds.
Generally, people with GSWs sustain greater injury than those with stab wounds because of a bullet’s proclivity to penetrate deeper and cause cavitation, damaging structures lying outside the tract of the missile. Bullets tend to course randomly and follow a more direct pathway. GSWs, particularly those involving high-velocity bullets (>2000-2500 ft/s) produced by military-style weapons or hunting rifles, generate shock waves that devitalize surrounding tissues. High-velocity missiles and their ensuing blast effects may suck debris into the wound tract or cause secondary injuries from bullet or bone fragmentation. Low-velocity injuries may be produced by .22- and .38-caliber handguns that have a muzzle speed of 800 ft/s.
A transcervical GSW is more likely to cause a grave injury than a GSW involving injury to only 1 side of the neck. Close-range GSWs of the neck that produce massive destruction are usually fatal. After a GSW to the neck, surgery is indicated in 75% of cases, while only 50% of neck stab wounds require surgical exploration.
Vascular injuries arising from penetrating trauma may occur directly, causing a partial or complete transection of the vessel or inducing formation of an intimal flap, arteriovenous fistula, or pseudoaneurysm. Blood vessel injury results from external compression, mural contusion, or thrombosis and is the most prevalent disorder arising from penetrating trauma, occurring in 25-40% of patients.
The internal jugular vein (9%) and carotid artery (7%) are the most common sites of vascular injuries. Injury to the pharynx or the esophagus occurs in 5-15% of cases. The larynx or the trachea is injured in 4-12% of cases.
Major nerve injury occurs in 3-8% of patients sustaining penetrating neck trauma. Spinal cord injury occurs infrequently and almost always results from direct injury rather than secondary osseous instability.
Blunt trauma
Blunt trauma to the neck typically results from motor vehicle accidents, but it also occurs with sports-related injuries (eg, clothesline tackle), strangulation, blows from the fists or feet, and excessive manipulation (ie, any manual operation, such as chiropractic treatment or physical realignment or repositioning of the spine).
In motor vehicle accidents in which the driver is not belted, the driver is in danger of thrusting forward with the head extended, forcing the anterior neck against the steering column. Shoulder harnesses appear to offer some, though incomplete, protection against blunt neck trauma; cerebral vessel and laryngeal injuries secondary to shoulder strap compression have occurred.
Nonpenetrating trauma can injure a blood vessel through a multitude of mechanisms. Direct forces can shear the vasculature. Excessive rotation and/or hyperextension of the cervical spine causes distention and stretching of the arteries and veins to the point of rupture. Intraoral trauma may extend to the blood supply. Basilar skull fractures may disrupt the intrapetrous portion of the carotid artery.
Impact to the exposed anterior aspect of the neck may crush the larynx or the trachea, particularly at the cricoid ring, and compress the esophagus against the posterior spinal column. A sudden increase in intratracheal pressure against a closed glottis (eg, improper wearing of a seat belt), a crush bruise (eg, clothesline tackle), or a rapid acceleration-deceleration action may cause a tracheal injury.
Strangulation may result from hanging (partial or complete suspension of the body from the neck), ligature suffocation, manual choking, and postural asphyxiation (eg, seen in children when the neck is placed over an object and the body weight produces compression). Significant cervical spine and spinal cord damage happens in only those hangings that involve a fall from a distance greater than the body height. Simple asphyxiation is not the major cause of death in hanging injuries. Cervical spinal disruption subsequent to strangulation is almost uniformly fatal.
Frequency:
In the US: Neck trauma accounts for 5-10% of all serious traumatic injuries. Approximately 3500 people per year die from neck trauma secondary to hanging, suicide, and accidents.
Mortality/Morbidity:
During the Vietnam era, when mandatory exploration and vascular repair was the standard of care for penetrating neck wounds, the mortality rate for the civilian population was 4-7%. Today, the overall mortality rate has decreased to 2-6%.
Initially missed cervical injuries secondary to neck trauma result in a mortality rate of greater than 15%. Ten percent of neck wounds lead to respiratory compromise. Loss of the airway patency may occur precipitously, resulting in mortality rates as high as 33%.
Zone I injuries are associated with the highest morbidity and mortality rates.
Race: Minorities experience a disproportionate share of inner city violence.
Sex: Trauma is more common among males.
Age: Most people who experience trauma are adolescents and young adults
History: Since many critical organs and structures remain at risk from neck trauma, clinical manifestations may vary greatly. The presence or absence of symptoms can be misleading, serving as a poor predictor of underlying damage. For example, only 10% of patients with blunt vascular damage develop symptoms in the first hour.
Use all available sources when trying to establish the mechanism of injury. Question the patient, involved bystanders, and prehospital personnel. Clarify events surrounding the traumatic event, establish the amount of time that elapsed since the injury, and confirm the patient’s baseline condition. Determine the amount of blood that was lost at the scene and whether the patient lost consciousness. Determine if any evidence of recent drug or alcohol ingestion is present.
When neck trauma results from a motor vehicle accident, inquire about seat belt use, location of the patient in the car (driver or front or back seat passenger), deployment of an air bag, and magnitude of car damage (eg, intrusion, steering column and windshield intact or broken).
In the event of a penetrating trauma, try to verify details about the weapon used, such as type and size of knife or type and caliber of gun.
For patients with injuries due to hanging, try to determine the suspension time (when the patient was last seen), drop height, ligature used, history of alcohol or drug abuse, and history of suicide attempts.
Characterize pain (eg, location, nature, intensity, onset, radiation), and document the nature and location of all stated injuries.
Cardiovascular manifestations range from bleeding to symptoms normally associated with a cerebrovascular accident.
Symptoms relating to the aerodigestive tract include dyspnea, hoarseness, dysphonia, and dysphagia.
CNS problems include paresthesias, weakness, plegia, and paresis.
Physical: Airway loss may occur precipitously. Determine airway patency, breathing, and adequacy of circulation. Fully expose the patient and note any disabilities. After completion of the primary survey, methodically examine the neck, searching for clues that indicate damage to vital contents. The sensitivity of the physical examination to identify all significant neck damage remains controversial. Some experts in the field of trauma assert that physical examination alone is sufficient to assess zone II for injury, while others believe that diagnostic testing is mandatory. The literature is not definitive. Most importantly, a single examination is never sufficient, since the onset of signs of injury may be delayed with neck trauma.
Search the neck for a breach of the platysma. Invested by the most superficial fascia, the platysma serves as the harbinger for serious penetrating neck wounds. Any violation of the platysmal muscle should alert the physician to the potential for grave damage to the contents of the neck. If the platysma is violated, judge whether the wound lies anterior (anterior triangle) or posterior (posterior triangle) to the sternocleidomastoid muscle, and determine in what zone the injury is found. Try to specify the direction of the wound tract (eg, toward or away from the midline or clavicle). Half of the cases of penetrating neck trauma in which the platysma is violated have no further injury. If the platysma clearly is not violated by a penetrating injury, the patient can be safely cleared of a significant underlying injury.
Consider an arterial injury of the neck in patients manifesting gross bleeding; a hematoma; asymmetry of arterial pulses; a new bruit on auscultation; neurological deficits, especially lateralizing cerebral findings; or hypotension. Do not unnecessarily probe or manipulate the wound or perform any action that may cause the patient to gag, choke, or cough. Any of these reactions may dislodge a clot and provoke a life-threatening hemorrhage.
Hard signs of an arterial injury include a large expanding hematoma, severe active or pulsatile bleeding, shock unresponsive to fluids, signs of cerebral infarction, presence of a bruit or thrill, and diminished distal pulses. Virtually all patients with hard signs of an arterial injury require operative repair.
Soft signs, such as a nonexpanding hematoma and paresthesias, do not improve the predictive value of an arterial injury more than indicating the proximity of the wound to a major vessel. The presence of a pulse does not exclude a vascular injury, nor is absence of a pulse diagnostic of vascular damage. Clinical findings are lacking initially in almost one third of patients with an arterial injury of the neck. Nearly one third of carotid artery injuries are associated with a central neurological deficit.
Perforation of the pharynx or the esophagus following blunt neck trauma rarely occurs. Initially, the patient may have no complaints, and the physical examination fails to reveal injury. Since the wall of the esophagus is fragile, iatrogenic injury can follow endoscopy, passage of a nasogastric tube, or inadvertent esophageal intubation. Esophageal perforation is the most serious and rapidly fatal trauma-induced perforation of the gastrointestinal tract.
Signs of spinal cord or brachial plexus injury
Brachial plexus injuries sustained from blunt trauma tend to involve the upper nerve roots (C5 to C7), diminishing the capacity of the upper arm while sparing strength and sensation of the lower arm. A radical avulsion of the brachial plexus results in a flaccid, numb extremity.
Quadriplegia occurring with complete transection of the spinal cord manifests as an absence of all motor, sensory, and reflex function below the level of injury. Bilateral neurological findings imply a spinal cord injury until proven differently.
Pathological reflexes, such as the Babinski reflex (extension of big toe) and Hoffmann sign (overactive muscle-stretch reflex), may be present.
Brown-S?quard syndrome results from hemisection of the spinal cord, causing ipsilateral motor paralysis with contralateral sensory deficits.
Priapism and loss of the bulbocavernous reflex may occur, and rectal tone may be poor.
Urinary retention, fecal incontinence, and paralytic ileus can occur from spinal cord damage.
Horner syndrome (ipsilateral miosis, enophthalmos, anhidrosis) results from disturbances of the stellate ganglion.
Neurogenic shock is a diagnosis of exclusion and is characterized by persistent bradycardia despite hypotension.
Hypoxia and hypoventilation can follow disruption of phrenic innervation to the diaphragm.
Signs of larynx or trachea injury
Voice alteration
Hemoptysis
Stridor
Drooling
Sucking, hissing, or air frothing through the neck wound (It may be provoked by coughing.)
Subcutaneous emphysema and/or crepitus
Hoarseness
Dyspnea
Distortion of the normal anatomic appearance (eg, loss of normal landmarks, asymmetry, flattened thyroid prominence, tracheal deviation)
Pain on palpation or with coughing or swallowing
Crepitus (This hallmark sign of disruption to aerodigestive tract is noteworthy in only one third of cases.)
Signs of penetrating injuries of the heart, aorta, and great vessels
Hemorrhage, usually associated with large wounds (eg, GSWs)
Massive hemothorax
Hypotension
Tamponade (if intrapericardial portion of aorta is injured)
Weak or absent carotid or brachial pulse
Paradoxical pulse (decrease in systolic BP with inspiration)
Bruit
Cervical or supraclavicular hematoma
Bleeding from the entrance wound
Upper extremity ischemia
Coma
Hemiparesis
Respiratory distress secondary to tracheal compression
Signs of tracheobronchial or lung injury
Subcutaneous emphysema
Cough
Respiratory distress
Hemoptysis, usually secondary to a disrupted bronchial artery
Tension pneumothorax
Continuous air leak persisting after chest tube insertion
Mediastinal crunch (Hamman crunch)
Intercostal retractions
Decreased breath sounds
Hyperresonance to percussion of the contralateral hemithorax, associated with hyperinflation of the unaffected lung
Tachypnea
Agitation
Hypotension
Tachycardia
Hypoxia
Shifting of the trachea and the apical heartbeat away from the injured side
Signs of carotid artery injury
Decreased level of consciousness
Contralateral hemiparesis
Hemorrhage
Hematoma
Dyspnea secondary to compression of the trachea
Thrill
Bruit
Pulse deficit
Signs of jugular vein injury
Hematoma
External hemorrhage
Hypotension
Signs of cranial nerve injuries
Facial nerve (cranial nerve VII): Drooping of the corner of the mouth
Spinal accessory nerve (cranial nerve XI): Inability to shrug a shoulder and to laterally rotate the chin to the opposite shoulder
Hypoglossal nerve (cranial nerve XII): Deviation of the tongue with protrusion
Thoracic duct injury usually is asymptomatic and tends to be an incidental finding during surgical exploration.
Signs of esophagus and pharynx injury
Dysphagia
Bloody saliva
Sucking neck wound
Bloody nasogastric aspirate
Pain and tenderness in the neck
Resistance of neck with passive motion testing
Crepitus
Bleeding from the mouth or nasogastric tube
Ligature marks: Examine the patient who has been strangulated. Note location and depth of marks, petechial hemorrhages of the skin and subconjunctival tissue (Tardieu spots), noisy or impaired respiration or phonation (eg, stridor, hoarseness, poor air movement), and palpable crepitus or tenderness over the larynx and trachea. Check for neurological deficits.
Causes: Neck trauma may be caused by penetrating or blunt trauma.
Penetrating trauma
GSWs
Stab wounds
Blunt trauma
Motor vehicle accidents
Sports-related injuries (eg, clothesline tackle)
Strangulation
Blows from fists or feet
Excessive manipulation (eg, any force causing a realignment or repositioning of the spine including iatrogenic carotid artery injury resulting from chiropractic treatment)
Lab Studies:
For any patient thought to have a neck injury, order the standard trauma blood studies (CBC, electrolytes, other warranted blood chemistry levels, blood type and cross-matching).
Generally, a CBC and blood typing suffice in a previously healthy individual, but patients with comorbid disease or those in shock may require additional studies, including a determination of coagulation profiles.
Order alcohol and toxicology screens, when indicated.
Imaging Studies:
Recognize the delay inherent with any imaging study. Do not delay transport to the operating room when the patient’s condition warrants emergent surgery.
Determining the specific study and order of testing depends on institutional preferences, mechanism of injury, and clinical scenario.
Detection of pharyngoesophageal injuries poses many problems, and a high index of suspicion is required because failure to diagnose these injuries can lead to significant morbidity and mortality.
Cervical x-rays
Unless indicated otherwise, most patients sustaining significant injury to the neck require plain-film radiography.
In general, order a 3-view series of the cervical spine.
Review the cervical radiographs for emphysema, fractures, displacement of the trachea, and presence of a foreign body (eg, missile fragments).
Chest x-ray
Any finding suggestive of a zone I wound or damage to the thoracic cavity mandates the ordering of a chest x-ray.
Circumspectly review the film for hemothorax, pneumothorax, widened mediastinum, mediastinal emphysema, apical pleural hematoma, and foreign bodies.
Supplementary tests
Order supplementary tests in the stable patient if specific system injuries are suggested by the history, physical, or prior ancillary studies. Additional imaging studies include the following: CT scans, MRIs, color flow Doppler studies, contrast studies of the esophagus, interventional angiograms, and endoscopic images.
CT scans prove most useful when bony or soft tissue damage is a consideration. Requesting a CT scan of the neck when a laryngeal fracture is suspected is especially important because clinically subtle injuries of the larynx often escape detection but become readily identifiable on CT scan. Recent studies are attempting to better define the role of helical CT scanning in identifying arterial injuries.
Consider an emergent MRI and/or magnetic resonance angiogram for evaluation of the patient exhibiting neurological impairment with minimal or absent abnormalities on plain radiographs of the cervical spine.
Some institutions now substitute color flow Doppler ultrasonography or use it as a screening test in low-risk patients or those thought to have a carotid injury. However, its sensitivity remains variable and its use, controversial.
Although a normal Gastrografin study occasionally proves useful in the evaluation of the cervical esophagus, it does not rule out a pharyngoesophageal leak. Deciding which contrast agent to use when studying the esophagus remains a subject of dispute among the experts. Advocates for Gastrografin use note that it is less likely than barium to cause an inflammatory response if extravasation through a breach occurs. However, barium induces less inflammation in the lungs; therefore, it poses less of a risk in the patient predisposed to aspiration.
Procedures:
Endoscopy
Laryngoscopy, bronchoscopy, pharyngoscopy, and esophagoscopy may be useful in the assessment of the aerodigestive tract. Rigid endoscopes are superior to flexible scopes.
Before inserting any scope, confirm that the airway is patent, intact, and protected (usually ensured by placement of an endotracheal tube). Ecchymosis of the posterior or lateral pharyngeal wall implies concealed neck damage.
Endoscopy, especially indirect laryngoscopy, often becomes problematical in the apprehensive trauma patient, and it may be best to defer examination until the airway is protected and the patient is anesthetized.
Angiography
Angiography routinely is employed to evaluate stable patients sustaining penetrating wounds to zones I and III that pierce the platysma. Angiography remains preferred to alternative contrast studies because it is less likely to obscure vascular damage.
A 4-vessel study is a prerequisite.
Preoperative arteriograms facilitate operative decision making, particularly when a question of intrathoracic involvement exists (such as with zone I injuries necessitating a thoracotomy). Otherwise, consider confirming adequacy of the collateral circulation if carotid artery ligation is contemplated (as may be necessary in zone III arterial wounds). Never send an unstable patient to a radiographic suite.
Occasionally, surgical exposure and access to bleeding vessels proves challenging, if not unattainable or impractical, and selecting therapeutic embolization or occlusion of the harmed vasculature remains a better option. This is achieved by placing an intravascular balloon tip catheter or shunt. However, discretion is critical because forceful placement of a catheter or shunt may dislodge a clot (eg, causing a stroke) or chance causing or exacerbating intimal damage, and even risk inauspicious perforation of the blood vessel.
Drawbacks include cost and the inherent danger of any vascular, particularly arterial, invasive procedure.
Prehospital Care: In most urban settings, immediate transport of the patient with neck trauma to the closest level I trauma setting is most appropriate because state-of-the-art care frequently necessitates a multidisciplinary approach.
Emergency medical personnel should restrict intubation attempts when anticipating a prolonged transport time, or when the patient appears apneic, pulseless, or moribund and respiratory arrest is imminent. Providing supplemental oxygen and clearing the airway of all secretions and foreign bodies, including unfastened dentures and loose teeth, frequently prove sufficient, practical, and helpful for the conscious patient.
Injudicious attempts to vigorously insert an endotracheal tube may worsen the patient’s state by running the risk of utterly marring the airway. Conversely (although less likely), ventilating the patient with a positive pressure bag-valve-mask device could exacerbate underlying subcutaneous emphysema, conceivably distorting the airway anatomy and impairing breathing and circulation.
In general, use impregnated gauze to cover sucking neck wounds or lacerations exuding bubbling air.
Patients sustaining significant blunt trauma require cervical spine precautions including cervical spine immobilization and supine placement of the patient on a backboard. Defer removal of helmets or other headgear until neck stabilization has been ensured.
Bleeding from the neck is best controlled with direct pressure.
Do not extract impaled objects in the field.
Establish intravenous access en route to the hospital; preferably place the catheter in the extremity opposite the side of the injury in case disruption of the ipsilateral venous circulation has occurred.
Emergency medical reports should relate the mechanism of injury, including the type of weapon involved, estimated amount of blood lost (EBL) at the scene, initial vital signs, noteworthy physical findings, and total transport time.
Emergency Department Care: Initial evaluation and stabilization includes securing the airway, controlling bleeding, providing cervical spine precautions, and identifying life-threatening conditions. Most blunt traumatic neck injuries can be managed nonoperatively. Surgical assessment of penetrating neck wounds usually requires a greater resolve for operative intervention, although prior axioms decreeing surgery as the only option are no longer as absolute. However, when a cut violates the platysma, it is sensible and prudent to engage a qualified surgeon, or transfer a stable patient to a trauma center where such care is available.
Airway
ED care of the patient with neck trauma commences with assessment and stabilization of the ABCs, starting with the airway first. Unfortunately, the same conditions compelling active airway management also intensify the obstacles to achieving successful intubation. Nonetheless, a wait-and-see attitude merely invites disaster.
Consequently, a preplanned strategy based on the expertise of the available staff, equipment at hand, the patient’s clinical condition, and the determined necessity for further testing should be planned before this scenario occurs. An entrenched partnership must exist among all potentially involved departments, especially emergency medicine, surgery, and anesthesiology.
Intubating a patient with penetrating neck trauma may incite gagging or coughing, potentially dislodging a clot and setting off massive bleeding from a previously injured blood vessel. Additionally, existent bleeding and edema rapidly distort the surrounding anatomy, making oral intubation difficult, if not impossible. Nevertheless, assessment of the airway takes priority over all other actions, including those procedures that risk exacerbating hemorrhage. Early preparation by the physician treating the patient is crucial. This includes ensuring ease of access to an acceptable suction apparatus and having multiple-sized endotracheal tubes as well as any tools and supplies necessary to perform the surgical airway procedure close at hand.
Before intubation, clear the mouth of foreign debris with the fingers or manual suction. Remedy partial airway occlusion originating from the tongue by performing a modified jaw thrust. (Never do a head-tilt chin-lift maneuver in a patient with a suspected cervical spine injury.)
Perform emergent intubation in patients displaying signs of acute or impending respiratory distress, such as perceptible noisy breathing; an inability to suitably handle blood, vomitus, or other body secretions; and obvious distortion of any neck landmarks, particularly tracheal deviation or existence of massive subcutaneous air. The choice of technique depends on the expertise of the attending staff and the capability to perform a surgical airway procedure. Despite concerns about converting a partially obstructed airway into a completely obstructed airway, a recent, retrospective series by Mandavia et al proved rapid sequence intubation to be safe and effective when performed by emergency physicians trained in this skill.
An awareness of potential laryngeal damage is imperative prior to intubation, even when the airway must be emergently secured. A neck hematoma can obscure landmarks, in addition to causing the danger of precipitating life-threatening exsanguination. Overwhelming suspicion for laryngeal injury directs execution of a surgical airway procedure to avoid injudicious endeavors at oral intubation that could sever a tenuously attached trachea or larynx, conceivably causing a catastrophe consequent to complete loss of the airway if the larynx detaches and dislodges into the chest.
Several large case series (eg, that by Shatney et al) demonstrate the safety of oral intubation with cervical in-line stabilization, provided direct laryngoscopy and intubation are performed in a gentle, atraumatic manner and explicit cervical spine immobilization is maintained. This is the preferred approach for the accomplished intubator in the patient with blunt trauma with suspected cervical spine injury.
Alternate techniques for securing the airway include fiberoptic intubation, gum elastic bougie, percutaneous transtracheal intubation, and wire-guided retrograde intubation. Additionally despite prior warnings, one study advocates the safety of blind nasotracheal intubation in the prehospital setting.
Fiberoptic intubation is a sensible course of action, especially for patients thought to have sustained a cervical spine injury or who exhibit gross distortion of the airway. Limitations include physician inexperience, lack of necessary equipment, and copious bleeding or secretions.
Percutaneous transtracheal intubation, also referred to as translaryngeal ventilation, is a quick and relatively simple technique in which a needle is inserted through the cricothyroid membrane and attached via a Y connector to an oxygen supply of at least 50 psi. This procedure is contraindicated when transection of the trachea or damage to the cricoid cartilage or the larynx is strongly suspected. Barotrauma may occur with percutaneous ventilation.
Retrograde tracheal intubation is an invasive procedure that may be suitable when excessive amounts of blood or secretions preclude fiberoptic intubation or when neck movement must be restricted.
Breathing
Signs or symptoms of respiratory embarrassment compel consideration for a hemothorax or a pneumothorax.
Zone I injuries may breach the chest cavity.
Ventilatory distress that persists beyond competent intubation indicates a possible tension pneumothorax, which requires needle decompression and chest tube placement.
Occlusion of the tracheobronchial tree, whether due to a foreign body or iatrogenic, is another cause of ventilatory problems.
Circulation
Control bleeding that originates from neck trauma with direct pressure or digitally. Do not blindly clamp a transected vessel, since inadvertent injury to adjacent structures or extension of blood vessel damage may occur. Never probe, cannulate, or locally explore these wounds in the ED because these actions may cause an air embolus or dislodge a clot and provoke bleeding. Do not remove objects protruding from the neck in the ED.
Concurrent with checking bleeding, establish intravenous access with at least 2 large-bore catheters (14 or 16 gauge). If there is a possibility of injury to the brachiocephalic or subclavian vein, place 1 intravenous access site in a lower extremity site and another access site in the upper extremity on the uninjured side.
Placing the patient in a mild Trendelenburg position to decrease the risk of air embolization may be advantageous.
In selected cases, bleeding that cannot be controlled or reached with direct pressure may benefit from balloon tamponade. Insert a Foley catheter into the wound. Direct it toward the site of bleeding, and inflate the balloon until bleeding resolves or moderate resistance is noted. As an example, for zone I injuries, slide in a Foley catheter toward the pleural cavity, and then inflate the balloon with sterile saline and retract it, striving to compress the injured subclavian vessel against the first rib or clavicle.
On rare occasions, such as with wounds in the pharynx, applying direct pressure to wounds may be impractical. These wounds may necessitate a cricothyroidotomy with subsequent packing of the pharynx as a temporary strategy.
Disability
Blunt neck trauma causes a wide spectrum of injuries ranging from a minor contusion or abrasion to life-threatening scenarios. Cervical spine injury remains a continual concern especially for patients sustaining significant blunt trauma to the head and/or neck.
Not only is the spinal cord vulnerable to injury, but so are other neural pathways like the phrenic, recurrent laryngeal, and lower lying cranial nerves, as well as the brachial plexus. Additionally, detection of a neurological deficit may signify damage to the carotid or vertebral artery with subsequent CNS ischemia.
Exposure
To view the anterior part of a neck that is concealed by a cervical collar, appoint an assistant to maintain the neck in a neutral position, and then remove the anterior aspect of the collar and proceed with the evaluation.
Expose and observe the patient’s entire body to avoid overlooking other potentially lethal injuries.
Miscellaneous
Once the patient is considered somewhat stable, the next step is to gently evaluate the neck wound to determine if the platysma has been violated. In this regard, the platysma is treated like the peritoneum of the abdomen; if it is violated, involvement of a qualified surgeon is mandatory. Even the most innocuous-appearing wound of the neck should not be probed or locally explored in the ED once a breach in the platysma is confirmed because a real risk of provoking clot dislodgment with subsequent secondary hemorrhage exists.
If no findings necessitating emergent surgeries are present, confer with a qualified trauma surgeon about further ED evaluation.
If the condition of a patient with penetrating neck trauma deteriorates to a state of cardiopulmonary arrest and the facility and the staff are qualified, perform an emergent thoracotomy to gain better control of the bleeding.
Consider cross-clamping the aorta and aspirating the right ventricle to forestall advancement of an air embolus.
It is usually best to avoid inserting a nasogastric (NG) tube until the airway is secured.
Consultations: Consult an experienced trauma surgeon emergently once platysmal violation is confirmed. Additional consultants should be prioritized with guidance from the trauma surgeon who will oversee the patient’s care.
Ordinarily, urgent surgical exploration of a penetrating wound to the neck is indicated for the following:
Continued blood loss, expanding hematoma, hypovolemic shock, and/or pulse deficit
Airway obstruction, impending airway obstruction, open trachea, and/or air bubbling from the wound site
Neurologic deficit
Blood in the aerodigestive tract, hemoptysis, and/or hematemesis
New-onset bruit
Infection subsequent to penetrating wounds of the neck is a major cause of death and disability. Administering prophylactic antibiotics, while not decisively validated by scientific studies, should be a consideration. Recommended medications vary from penicillin to those with broad-spectrum coverage. Factors to consider include the physical nature of the injury (eg, simple laceration vs blunt trauma with tearing-type injuries). If prophylactic antibiotics are to be effective, attempt to obtain adequate tissue levels immediately, preferably within 4 h of injury.
Other therapeutic agents to consider are the corticosteroids. Massive doses of steroids are believed to have possible benefit in improving neurological function in selected subsets of patients. In the second phase of a benchmark study (Bracken et al), patients who had sustained blunt spinal injury within a 12-h time frame were given a 30 mg/kg IV bolus of corticosteroids followed by 5.4 mg/kg/h for 23 h. Overall, patients who appropriately received steroids within 8 h revealed slight improvement in function in motor and sensory function at 6 mo. Other experimental agents include naloxone, dimethylsulfoxide, and growth factors. Spinal cooling also has been proposed.
Drugs facilitating endotracheal intubation, especially those used for rapid sequence intubation, should be readily available.
Drug Category: Antibiotics – Therapy must cover all likely pathogens in the context of the clinical setting.Drug Name
Cefotetan (Cefotan) – Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.
Adult Dose 1-2 g IV/IM q12h
Pediatric Dose 20-40 mg/kg/dose IV/IM q12h
Contraindications Documented hypersensitivity
Interactions Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity; monitor renal function
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Reduce dosage by one half if CrCl <10-30 mL/min and by one fourth if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Drug Name
Gentamicin (Garamycin) – Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Adult Dose 3-5 mg/kg/d IV/IM q6-8h
Follow each regimen by at least a trough level drawn with the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion
Pediatric Dose <5 years: 2.5 mg/kg/dose IV/IM q8h
5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults
Contraindications Documented hypersensitivity; renal insufficiency not dependent on dialysis
Interactions Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patient not undergoing dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Drug Name
Ampicillin (Omnipen) – Bactericidal activity against susceptible organisms. Alternative to amoxicillin when patient unable to take medication orally.
Adult Dose 1-2 g IV/IM q4-6h
Pediatric Dose 50 mg/kg IV/IM q4-6h
Contraindications Documented hypersensitivity
Interactions Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Drug Name
Clindamycin (Cleocin) – Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose 600-1200 mg/d IV/IM divided q6-8h depending on degree of the infection
Pediatric Dose 20-40 mg/kg/d IV/IM divided tid/qid; may increase dose to 16-20 mg/kg/d divided tid/qid for severe infections
Contraindications Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Interactions Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Drug Name
Ceftriaxone (Rocephin) – Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.
Adult Dose 1-2 g IV qd, or divided bid; not to exceed 4 g/d
Pediatric Dose >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Contraindications Documented hypersensitivity
Interactions Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment; caution in breastfeeding women and patients with allergy to penicillin
Further Inpatient Care:
Standing protocols dictating the treatment of patients with neck trauma must be in place. Such guidelines should indicate which patients require emergent surgery, transfer, or further workup.
A major disadvantage of exploring all penetrating neck injuries with platysma violation is a nontherapeutic exploration in approximately 50% of cases. This results in unnecessary costs and nonessential invasive procedures. Recent studies (eg, those by Demetriades et al and Ngakane et al) suggest that the majority of patients with penetrating neck trauma can be treated nonoperatively. No definitive recommendation exists, and treatment protocols should be based on a multidisciplinary agreement within the institution. However, because of the prospect of occult injuries with zone I and III wounds, a relatively aggressive workup is warranted. The definitive evaluation and management of penetrating trauma in particular, continues to evolve.
Decisions regarding whether to ligate or repair arterial injuries rely on the presence or absence of a major neurological deficit (coma and/or paralysis); some surgeons prefer to avoid the danger of reperfusion injury of the brain.
Embolization may halt bleeding from a damaged vessel in the neck.
If the patient’s vital signs are not stabilized, death in the radiological suite is a real risk.
Temporary occlusion of the blood vessel may be achieved by insertion of a gelatin sponge (Gelfoam).
Further Outpatient Care:
Observe patients with all but the most trivial of neck wounds for delayed onset of symptoms.
Platysma violation usually justifies admission for 24 hours of observation to avoid missing occult injuries, particularly vascular and esophageal wounds.
Decisions regarding the need to admit a patient with blunt neck trauma are based on the presence or absence of signs and symptoms, as well as the patient’s underlying physiological status and factors such as the availability of care, extent of care warranted, and willingness of responsible parties to participate.
Many patients are discharged with the diagnosis of whiplash injury, which is neck pain following sudden flexion-extension of the head, eg, with a rear-end motor vehicle accident. By definition, whiplash injury implies that bony damage or other significant injuries are excluded. In addition, the pain originates from a stretching and bruising of the neighboring musculature and supporting ligaments.
Care for lacerations superficial to the platysma in an otherwise asymptomatic patient as one would care for cuts elsewhere in the body. Clean lacerations may be sutured as late as 12-18 hours after injury, since, ordinarily, the neck is exceptionally well perfused.
In/Out Patient Meds:
Outpatient treatment for minor neck injuries may include use of various analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs, for mild neck strains or sprains.
Check the tetanus status on all patients sustaining penetrating neck wounds.
Transfer:
All consequential neck injuries are best managed in a level I trauma center.
Arrangements to transfer such patients are made concurrently with stabilization of the airway and hemorrhage control.
Deterrence/Prevention:
Establish injury prevention programs.
Support efforts to limit violence in society.
Provide instruction on the proper use of seat belts.
Complications:
Airway obstruction may result from evolving tracheal and/or laryngeal edema or stenosis. Vocal cord paralysis and voice change also may follow laryngeal trauma.
Swallowing dysfunctions may affect patients with neck trauma.
Aspiration of material (eg, blood, vomitus) is always a possibility.
Patients who survive the initial strangulation injury may succumb to pulmonary edema or bronchopneumonia.
Unrecognized vascular injury may lead to delayed exsanguination (rupture of clot with hemorrhage), clot embolization or thrombosis, and/or formation of a false channel (pseudoaneurysm) or arteriovenous fistula, which can both evolve into delayed hemorrhage. Vascular injuries subsequent to blunt trauma specifically are associated with a high complication rate. Approximately 10% of patients are asymptomatic in the first hour.
Soft tissue necrotizing infections caused by mixed bacterial organisms may originate from contamination of the neck or extravasation from oral wounds. Sepsis, mediastinitis, and cervical osteomyelitis may occur.
Fistulas include tract formation between the trachea and the esophagus (tracheoesophageal fistula), the trachea and the brachiocephalic artery (potential for a catastrophic hemorrhage within the tracheobronchial tree), and the esophagus and the skin (esophagocutaneous fistula).
Complications associated with arteriography range from arterial wall injuries (eg, intimal flaps, thrombosis, and severe vascular spasm) to neurological impairment, anaphylactic reaction, and groin hematoma (may lead to femoral artery occlusion).
Air embolism is an infrequent seldom-mentioned complication that arises from tears in the major neck veins. Penetrating neck trauma may precipitate an air embolism. Depending on where the embolus settles, positioning the patient may lessen the chance of embolus propagation. Suspect this entity in patients developing unexpected hypotension and/or arrhythmia, especially in the setting of an increase in central venous pressure.
Lead intoxication is an unusual problem that occurs subsequent to a bullet remaining lodged in the neck, usually in a joint space. Warning signs and symptoms include abdominal pain, nephropathy, and unexplained anemia.
Zone I wounds are often associated with thoracic injury causing a pneumothorax, hemothorax, or tension pneumothorax.
Prognosis:
As a general rule, zone I injuries have the worst prognosis in regard to imminent morbidity and mortality.
Zone II injuries are the most prevalent penetrating neck wounds. Because of their accessibility, injuries in zone II have the best prognosis.
Zone III presents unique therapeutic and diagnostic challenges because of its secluded nature of the critical structures spanning this locale.
Complete disruption of the spinal cord above C4 is frequently fatal. Preservation of any neurological function, including rectal tone, following a spinal cord injury improves the outlook.
Vascular injuries arising from blunt trauma are associated with a poor outcome.
The prognosis is poor when severe neurological deficits (eg, hemiparesis, coma) occur subsequent to carotid artery damage. Early revascularization may improve the outlook.
Identification of pharyngeal or esophageal injuries is paramount because delayed diagnosis leads to significant morbidity.
Strangulation patients presenting in cardiac arrest have a dismal prognosis, as do strangulation patients who are successfully resuscitated but who completely lack neurological function.
If the Glasgow score is greater than 3, the chances are good that the patient with a choking or strangulation injury will eventually be discharged neurologically intact.
Overall, the present mortality rate for civilian wounds secondary to penetrating neck trauma is 2-6%. However, injury to a major blood vessel results in fatality almost 65% of the time, including prehospital deaths.
Patient Education:
Soft tissue cervical strains and sprains, commonly known as a whiplash injuries, initially may be associated with minimal pain.
Subsequent edema and medicolegal considerations may cause worsening of symptoms over the ensuing 24-48 hours.
Instruct the patient that complete resolution of symptoms may require 2-12 weeks. Stress the importance of follow-up care.
Recommendations regarding the use of alternate modalities (eg, cold, heat, manipulation, massage) depend on what works best for the patient. Discourage the prolonged use of soft collars.
Patients who sustain superficial lacerations and are discharged should be supplied with adequate instructions for caring for wounds.
For excellent patient education resources, visit eMedicine’s Back, Ribs, Neck, and Head Center. Also, see eMedicine’s patient education articles Whiplash and Child Passenger Safety
Medical/Legal Pitfalls:
Achievement of a protected airway takes priority over all other actions. When intubating the patient, do not force the endotracheal tube into the trachea because this can cause complete severance of a partially transected airway or displace the trachea into the mediastinum. While the fear of a failed difficult airway in an apneic patient is a legitimate concern and should not be taken lightly, in critically injured patients the benefit of a secured airway likely outweighs the risk induced by acute paralysis.
Coexisting head injury, coma, spinal cord damage, or drug and/or alcohol impairment may distort findings in the neck trauma patient.
If the condition of a patient with a penetrating neck wound continues to deteriorate despite resuscitation, consider an intrathoracic injury, such as massive hemothorax or tension pneumothorax.
If an injury to the jugular vein is suspected, position the patient’s head lower than the heart to reduce the risk of air embolization.
Presence of a neurologic deficit, especially one contralateral to the side of injury, should prompt speculation of an injury to the carotid or vertebral artery, in addition to nerve injury.
Do not remove an impaled object in the ED because the object may be causing tamponade to stop the hemorrhage.
Never accept suboptimal imaging studies. Ensure that the physician interpreting the image is sufficiently qualified.
Physical findings in a neck wound tend to be deceptive. An apparently insignificant hematoma may conceal a larger, deeply confined subfascial accumulation of blood. Do not probe neck wounds that penetrate the platysma in the ED; this may dislodge a clot, causing a massive hemothorax or creating an iatrogenic pneumothorax.
Do not send a patient with a compromised airway to a darkened, nonequipped angiographic suite. Consider prophylactic intubation in a controlled setting.
Do not blindly clamp blood vessels because other vital structures (eg, nerves) travel alongside and may be irreparably damaged. Direct pressure is usually sufficient.
Special Concerns:
Pregnancy
Consider the physiological changes that occur with pregnancy in any gravid patient who sustains trauma. Specifically, blood pressure decreases 10-15 mm Hg systolic and 5-10 mm Hg diastolic, the heart rate increases 10-15 beats per minute, and physiological anemia accompanies pregnancy. Since fetal viability relies completely on satisfactory maternal cardiopulmonary perfusion (the fetus is termed the “yellow canary” for the mother), focus all efforts on resuscitating the mother. Pay particular attention to oxygenation.
Maternal cardiac output depends greatly on venous return, which is influenced by the position of the mother during late pregnancy. Supine positioning allows the gravid uterus to compress the inferior vena cava, and cardiac output may be increased by 30% with the patient in the lateral recumbent position. If cervical spine injury remains a concern, the uterus may be manually displaced.
After restoration of maternal oxygenation and circulation, evaluate the mother for secondary injuries and rapidly assess the fetus. If the fetal parameters suggest potential viability (eg, >24 wk), obtain an obstetric consultation.
Try to limit ionizing radiation exposure to the patient during early pregnancy, and use ultrasound for evaluation, when suitable.
Pediatric
Generally, children’s heads and mandibles are proportionally larger than their adult counterparts. Children’s necks tend to be relatively smaller that those of adults, lessening the risk of direct anterior damage to the neck. The head and chest protrude more anteriorly and are more likely to absorb traumatic forces than the neck. However, the proportionately larger head of children leaves the neck more vulnerable to acceleration-deceleration forces.
Internal anatomy is different between children and adults (eg, in children the larynx is higher in the neck and the narrowest portion is at the C4 level compared with C7 in adults). Additionally, the necks of children are generally more flexible; therefore, plain-film radiographs may not reveal serious neck injuries.
Always consider child abuse in children with any type of injury.
Spinal cord abnormality without radiological abnormality syndrome has a reported prevalence of 4-66% of all significant cervical spinal injuries in children. Suspect this injury in any child with neck trauma, especially those with hyperextension injuries and neurological deficits without abnormalities on plain-film radiographs. An MRI becomes the image of choice to rule out spinal cord injury.
Geriatric
Aging tends to compromise physiological reserves, making it difficult to assess commonly used parameters of hemodynamic status.
Degenerative and arthritic changes hinder radiological evaluation.
Elderly patients sustaining blunt trauma to the neck are more predisposed to central cord compression, especially after hyperextension injuries in which the spinal cord becomes compressed between osteophytes anteriorly and the buckling ligamentum flavum posteriorly.
Elderly patients sustaining carotid artery injury without coexisting neurological deficits may require an extracranial-intracranial bypass.
Caption: Picture 1. Neck trauma. Zones of the neck.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Image
Caption: Picture 2. Neck trauma. Zone I injury.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 3. Neck trauma. Zone II injury.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 4. Neck trauma. Zone III injury.
View Full Size Image
eMedicine Zoom View (Interactive!)
Abujamra L, Joseph MM: Penetrating neck injuries in children: a retrospective review. Pediatr Emerg Care 2003 Oct; 19(5): 308-13[Medline].
Arishita GI, Vayer JS, Bellamy RF: Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma 1989; 29: 332-7[Medline].
Azuaje RE, Jacobson LE, Glover J, et al: Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg 2003 Sep; 69(9): 804-7[Medline].
Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990 May 17; 322(20): 1405-11[Medline].
Brimacombe J, Keller C, Kunzel KH, et al: Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers. Anesth Analg 2000 Nov; 91(5): 1274-8[Medline].
Carducci B, Lowe RA, Dalsey W: Penetrating neck trauma: consensus and controversies. Ann Emerg Med 1986 Feb; 15(2): 208-15[Medline].
Criswell JC, Parr MJ, Nolan JP: Emergency airway management in patients with cervical spine injuries. Anaesthesia 1994 Oct; 49(10): 900-3[Medline].
DeBehnke DJ: Intubation of patients with cervical spine injuries. Am J Emerg Med 1992 Sep; 10(5): 506[Medline].
Demetriades D, Asensio JA, Velmahos G, Thal E: Complex problems in penetrating neck trauma. Surg Clin North Am 1996 Aug; 76(4): 661-83[Medline].
Gracias VH, Reilly PM, Philpott J, et al: Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg 2001 Nov; 136(11): 1231-5[Medline].
Kim MK, Buckman R, Szeremeta W: Penetrating neck trauma in children: an urban hospital’s experience. Otolaryngol Head Neck Surg 2000 Oct; 123(4): 439-43[Medline].
Kupcha PC, An HS, Cotler JM: Gunshot wounds to the cervical spine. Spine 1990 Oct; 15(10): 1058-63[Medline].
Mandavia DP, Qualls S, Rokos I: Emergency airway management in penetrating neck injury. Ann Emerg Med 2000 Mar; 35(3): 221-5[Medline].
McConnell DB, Trunkey DD: Management of penetrating trauma to the neck. Adv Surg 1994; 27: 97-127[Medline].
Phrampus PE, Walker L: Danger zone. The prehospital assessment & treatment of blunt & penetrating neck trauma. JEMS 2002 Nov; 27(11): 26-38; quiz 40-1[Medline].
Reece GP, Shatney CH: Blunt injuries of the cervical trachea: review of 51 patients. South Med J 1988 Dec; 81(12): 1542-8[Medline].
Shatney CH, Brunner RD, Nguyen TQ: The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg 1995 Dec; 170(6): 676-9; discussion 679-80[Medline].
Stassen NA, Hoth JJ, Scott MJ: Laryngotracheal injuries: does injury mechanism matter? Am Surg 2004; 70(6): 522-5[Medline].
Steinfeldt J, Bey TA, Rich JM: Use of a gum elastic bougie (GEB) in a zone II penetrating neck trauma: a case report. J Emerg Med 2003 Apr; 24(3): 267-70[Medline].
Thompson EC, Porter JM, Fernandez LG: Penetrating neck trauma: an overview of management. J Oral Maxillofac Surg 2002 Aug; 60(8): 918-23[Medline].
Vander Krol L, Wolf
Martial Arts in America are incredibly over rated. Most of these guys learn some silly looking dance moves, write out a check to the instructor, and collect their belts.
I’ve personally seen some sorry assed black belts get the holy shit kicked out of them by guys that had no more fighting experience than a few years of high school wrestling as their skill set.