Approach to Penetrating
Neck Trauma
A case…
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BK, 49 yo male self-inflicted stab wound to neck
Found by EMS with steak knife nearby
 Unknown time down
 Unknown head strike, unknown LOC.
 At scene patient was awake but non-communicative
 En route vitals stable
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A case…(cont.)
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PMH: unknown
PSH: unknown
Meds: unknown
All: unknown
Last meal: unknown
A case…(cont.)
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On arrival…
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Vitals: T 98.0 BP 220/117 P 110 R 18 SaO2 100%RA
Gen: Awake and talking but not following commands. No stridor or
hoarseness in voice.
HEENT: PERRLA, EOMI.
Neck: 2 cm laceration Zone II along anterior boarder of right SCM.
Minimal bleeding from wound and a non-expanding hematoma was
present.
CV: Tachycardia, reg rhythm
Pulm: CTA B/L
Abd: Soft, NT, ND. (+) BS.
Rectal: Normal tone. No gross blood
Ext: No gross deformities.
Neuro: No focal deficits. Spontaneous movement all 4 extremities.
A case…(cont.)
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CT head – negative
CT neck – hematoma over R SCM. Trachea and
esophagus intact.
A case…(cont.)
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Taken to OR for wound exploration
Findings: Underlying hematoma. Active
bleeding from penetrating vessels of right SCM.
No major vascular injury. No tracheal or
esophageal injuries
Penetrating Neck Trauma
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Management algorithm is not universal and is
constantly evolving
Recommendations range from surgical
exploration of everyone (Roon et al, 1979) to
selective observation (Meinke et al, 1979)
Also depends on hospital’s availability of
resources (ie. CTA/endoscopy)
Penetrating Neck Trauma
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Two major types of injuries
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Major vascular injury
Esophageal/bronchial injury
Major Vascular Injury
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Strong suspicion: severe active hemorrhage,
refractory shock, absent ipsilateral pulse, neuro
deficit
Weak suspicion: bruit, widened mediastinum,
hematoma, diminished UE pulses, shock
responsive to resuscitation
Evaluation: surgical exploration, CTA or
angiogram
Aeorodigestive Tract Injury
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Signs/symptoms: hemoptysis, hoarseness,
odynophagia, SQ emphysema, hematemesis
Evaluation:
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Bronchoscopy
Esophagoscopy or Gastrografin
swallow
Management Algorithms
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Management depends on
level of injury:
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Zone I – Thoracic inlet to
cricothyroid membrane.
Zone II – Cricothyroid
membrane to angle of
mandible
Zone III – Angle of
mandible to base of skull
 Also depends on depth (superficial to platysma should be irrigated,
debrided, closed primarily)
Zone I Injuries
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Only 5% require operation
CT angiogram or angiography widely advocated
 Min invasive techniques preferred for repair (embolization,
endovascular stenting)
Suspicion for aerobronchial injury?
 Bronchoscopy/esophagoscopy/Gastrografin swallow
Zone III Injuries
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Surgery generally avoided due to difficult
exposure
CTA if clinical evidence of vascular injury
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Min invasive techniques preferred
Bronch/esophagoscopy if evidence of
aerodigestive injury
Zone II Injury
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Highly controversial
Wide spectrum of recommendations
All agree that unstable patients or those with obvious
vascular, tracheal or esophageal injury require surgical
exploration
What about the stable patients?
Zone II Injury
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Surgical exploration for everyone?
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Pros:
Easy exposure of vital structures
 Low morbidity/mortality of procedure
 Discovery of subclinical injuries
 Better hemostasis
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Cons:
Cost (1981: estimated cost of exploration $1,930)
 High percentage of negative explorations (50-68% in
most series)
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Zone II Vascular Injury
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CTA, duplex U/S and angiography have all been
advocated
CT can help define trajectory of penetrating
object (proximity to vital structures)
Zone II Esophageal/Bronchial
Injury
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Bronchoscopy/esophagoscopy/Gastrografin
swallow (same as I and III)
Zone II Recommendations
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Mandatory exploration and selective observation
are both acceptable strategies
Large academic centers more likely to have
resources to evaluate and monitor patients 24
hours/day
Operative Approach
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Exposure: Incision along anterior boarder of SCM
(most common)
Arterial injuries: primary repair (preferred) vs.
prosthetic grafts
Venous injuries: ligate
Tracheal/esophageal injuries: primary repair.
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Place drain to avoid mediastinitis from enteric content leak
If both are injured a muscle flap placed between injuries can
prevent TE fistula formation
References
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Ayuyao AM, Kaledzi YL, Parsa MH, Freeman HP. Penetrating neck wounds. Mandatory versus
selective exploration. Annals of Surgery. 1985;202:563-567.
Demetriades D, Theodorou D, Cornwell E, 3rd, et al. Penetrating injuries of the neck in patients
in stable condition. Physical examination, angiography, or color flow doppler imaging. Archives of
Surgery. 1995;130:971-975.
Jurkovich GJ, Zingarelli W, Wallace J, Curreri PW. Penetrating neck trauma: Diagnostic studies in
the asymptomatic patient. Journal of Trauma-Injury Infection & Critical Care. 1985;25:819-822.
Klingensmith ME, Chen LE, glasgow SC, et al. The Washington Manual of Surgery, 5th ed.
Lippincott Williams & Wilkins. 2008; 375-377
Nemzek WR, Hecht ST, Donald PJ, et al. Prediction of major vascular injury in patients with
gunshot wounds to the neck. Ajnr: American Journal of Neuroradiology. 1996;17:161-167.
Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. Journal of
Trauma-Injury Infection & Critical Care. 1979;19:391-397.
Saletta JD, Lowe RJ, Lim LT, et al. Penetrating trauma of the neck. Journal of Trauma- Injury
Infection & Critical Care. 1976;16:579-587.
Thomas AN, Goodman PC, Roon AJ. Role of angiography in cervicothoracic trauma. Journal of
Thoracic & Cardiovascular Surgery. 1978;76:633-638.
Tisherman SA, Bokhari F, Collier B, et al. Clinical Practice Guidelines: Penetrating Neck Trauma.
Eastern Association for the Surgery of Trauma. 2008