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
- Physical examination regardless of the zone of injury should be the primary guide to dictate further evaluation: CTA vs open exploration
- Zone 2 injuries are the most common, followed by Zone 1, and then Zone 31
- Zone 2 is amenable to operative exploration, the others are harder to get to
- Don’t forget the other vital structures in the neck, ie the airway and esophagus
References
- McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg. 1994;27:97–127. PMID: 8140981
- Bryant AS, Cerfolio RJ. Esophageal trauma. Thorac Surg Clin. 2007;17(1):63–72. doi: 10.1016/j.thorsurg.2007.02.003. PMID: 17650698
- Lydiatt MW, Snyder CM, Lydiatt DD. [updated];Penetrating Injuries of the Neck: Follow-up.; 2009 Available from: http://emedicine.medscape.com/article/869579-followup.
- 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
- 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.
Excellent summary.
Is there a part 2?
Yes! Here ya go: https://criticalcarenow.com/2020/09/29/get-in-the-zone-penetrating-neck-trauma-part-2/
Just released this week.