Get in the Zone: Penetrating Neck Trauma Part 1

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The Pre-brief

The main directive of evaluating neck trauma is looking for vascular injury (plus a few other vital things…). If you look at the system from a vascular perspective, the heart is where it all starts – so ZONE 1 is closest to the heart, ZONE 3 the furthest.

Zones of Penetrating Neck Trauma

Zone 3: Above angle of the mandible

  • Evaluation: angiography

Zone 2: Cricoid cartilage to angle of the mandible

  •  Evaluation: open exploration, CT/CTA, observe, +/- EGD/esophagoscopy, bronchoscopy

Zone 1: Below the cricoid cartilage

  •    Evaluation: angiography, EGD/esophagoscopy, bronchoscopy

Zone 2 injuries are the most common, followed by Zone 1, and then Zone 31

Vascular injury is the most common complication of penetrating neck trauma, occurring in 25%, with mortality of nearly 50%.2

Of note, there is a concept of “No Zone”. Stable penetrating neck trauma patients, regardless of zone, should first undergo CTA. This may better elucidate vascular vs airway vs esophageal injuries.

Vascular Injury HARD SIGNS

  • Bruit over/near the artery on auscultation
  • Expanding hematoma
  • Distal ischemia
  • Pulsatile bleeding
  • Thrill on manual palpation

Aerodigestive Injury HARD SIGNS

  • Airway compromise
  • Bubbling wound
  • Subcutaneous emphysema
  • Stridor
  • Hemoptysis or hematemesis

Penetrating Trauma

  • 3-6% current mortality rate for penetrating neck injury
  • 50% of deaths caused by hemorrhage from vascular injuries.
  • 40% of penetrating neck injuries are associated with vascular injury
  • 10% injury to the carotid artery
  • 23–30% have associated GI tract injuries
  • Esophageal injuries are associated with 11-17% mortality rate3

Vascular Injury SOFT SIGNS

  • Diminished ipsilateral distal pulse
  • Non-expanding/non-pulsatile hematoma
  • History of arterial bleeding on scene
  • Peripheral nerve deficit
  • Unexplained hypotension
  • High-risk orthopedic injury (medial clavicle fracture)
  • Hoarse voice
  • Dysphonia

Blunt Trauma

  • Must include cervical spine injury in evaluation
  • Delayed laryngeal, vascular and GI tract injuries possible
  • Consider blunt cervical vascular injury in high speed MVA +/- neck seat belt sign

The Debrief

  1. Physical examination regardless of the zone of injury should be the primary guide to dictate further evaluation: CTA vs open exploration
  2. Zone 2 injuries are the most common, followed by Zone 1, and then Zone 31
  3. Zone 2 is amenable to operative exploration, the others are harder to get to
  4. Don’t forget the other vital structures in the neck, ie the airway and esophagus


  1. McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg. 1994;27:97–127. PMID: 8140981
  2. Bryant AS, Cerfolio RJ. Esophageal trauma. Thorac Surg Clin. 2007;17(1):63–72. doi: 10.1016/j.thorsurg.2007.02.003. PMID: 17650698
  3. Lydiatt MW, Snyder CM, Lydiatt DD. [updated];Penetrating Injuries of the Neck: Follow-up.; 2009 Available from:
  4. Sperry JL et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013; 75(6): 936-41. PMID: 24256663
  5. Ibraheem K, Khan M, Rhee P, et al. “No zone” approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res. 2018;221:113-120. PMID: 29229116.


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