Penetrating Neck Injuries Init

Penetrating neck injuries: Initial evaluation and management
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Official reprint from UpToDate

www.uptodate.com 2015 UpToDate

Author
Kim Newton, MD
Section Editors
Maria E Moreira, MD
Richard G Bachur, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2015. | This topic last updated: Sep 14, 2015.
INTRODUCTION Penetrating neck injuries (PNIs) refer to neck injuries induced by gunshot wounds, stab
wounds, or penetrating debris, such as glass or shrapnel. Before World War II, all PNIs were treated
expectantly and mortality rates were as high as 35 percent [1]. In an attempt to reduce the high death rates
associated with PNIs, a mandatory surgical approach was adopted, even for stable patients. This approach
reduced mortality rates [2].
Mandatory surgical exploration remained widely accepted well into the 1990s, when it became obvious that
while the mortality rate was low, the rate of negative surgical explorations was unacceptably high (58 percent in
one series) [3]. From this observation came the concept of selective surgical management, which offers a
spectrum of diagnostic approaches.
PNI, defined by platysma violation, comprises a sizable number of traumatic injuries in adults and remains a
difficult management issue [1]. While surgical intervention is necessary in approximately 15 to 20 percent of PNI
cases, the management of stable patients remains a source of debate [1,4,5].
The management of PNIs will be reviewed here. Traumatic shock and other trauma topics are discussed
separately. (See "Initial evaluation and management of shock in adult trauma" and "Initial management of
trauma in adults".)
EPIDEMIOLOGY Penetrating neck injury (PNI) comprises 5 to 10 percent of traumatic injuries in adults and
is caused primarily by bullets, knives, and other impaling objects (eg, shrapnel, glass) [6]. Wounds caused by
low velocity guns or impaling objects tend to cause fewer aerodigestive and vascular injuries [7]. High velocity
injuries carry a greater likelihood of serious injury and death [8]. Overall mortality ranges from 3 to 10 percent
[9,10].
PNI is categorized by anatomic zones, which are described below. Mortality in patients with PNI appears to be
highest with zone I injuries (below the cricoid cartilage) because of the nature of the vascular injuries and the
risks inherent in more difficult surgical explorations [1]. Exsanguination is the most common cause of death, and
the carotid artery is the structure most often involved [1,2]. The incidence of carotid artery injury in PNI ranges
from 6 to 17 percent [11,12]. (See 'Anatomy' below.)
One review of studies published from 1963 through 1990 included over 2495 patients with PNI and reported
that zone II injuries are most common, followed by zone I then zone III [2]. According to this review, the
aerodigestive tract was injured most frequently. Ten percent of such patients had laryngeal or tracheal injury
and 9.6 percent had pharyngeal or esophageal wounds. Vascular injuries were also common: 9 percent had
internal jugular vein injury and 6.7 percent carotid artery injury. Spinal cord injury occurred in 3 percent. Less
common injuries included the subclavian artery (2.2 percent), vertebral artery (1.3 percent), brachial plexus (1.9
percent), cranial nerves 9 and 10 (0.9 percent), and the thoracic duct (<0.1 percent).
Mortality from penetrating laryngotracheal trauma is reported to be 20 percent [5]. Mortality from
pharyngoesophageal injuries is as high as 22 percent [11,13]. Unstable cervical spinal column injuries are rare
following PNI [14].
http://www.uptodate.com/contents/penetrating-neck-injuries-initial-evaluation-and-manag... 27-Dec-15
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ANATOMY Neck anatomy is complex with aerodigestive and neurovascular structures confined to a small
area.
Clinicians generally describe penetrating neck trauma according to the zone of injury [15]. The neck is divided
into three zones (figure 1). Zone I is the most caudal and includes the base of the neck and thoracic inlet. It
extends from the sternal notch and clavicles to the cricoid cartilage. Zone I contains the thoracic outlet
vasculature, vertebral and proximal carotid arteries, apices of the lungs, trachea, esophagus, spinal cord, and
thoracic duct. Zone II (midneck) continues cephalad from the cricoid cartilage to the angle of the mandible, and
contains the jugular veins, vertebral and common carotid arteries, and internal and external branches of the
carotid arteries, as well as the trachea, esophagus, larynx, and spinal cord. Zone III (upper neck) includes the
region above the angle of the mandible up to the base of the skull and contains the pharynx along with the
jugular veins, vertebral arteries, and the distal portion of the internal carotid arteries. Zone designation carries
implications for management and prognosis. Zone I injuries can involve the mediastinum and control of vascular
injuries can be difficult. Zone III vascular injuries, especially those more cephalad, pose a surgical challenge.
Penetrating injuries can transgress zone boundaries depending upon the implement or projectile and its angle
of penetration. Therefore, clinicians must consider the possibility of injuries within zones other than that
containing the entry wound. As an example, PNI sustained from a downward stab wound that enters the
anterior neck in zone II may also injure the lungs and mediastinal structures. To avoid artificial constraints on
the diagnoses considered and decrease the reliance on invasive testing, a No Zone algorithm has been
introduced [16].
The neck can also be divided into triangles (figure 2). The anterior triangle is bordered anteriorly by the midline,
posteriorly by the sternocleidomastoid muscle, and superiorly by the lower edge of the mandible. The posterior
triangle is located within the boundaries of the sternocleidomastoid muscle anteriorly, the clavicle inferiorly, and
the anterior border of the trapezius muscle posteriorly. Most vital structures are located in the anterior triangle.
Trauma to the posterior triangle, excluding the spine, carries a much lower likelihood of significant injury.
The neck has several fascial compartments. These compartments can help to contain bleeding from some
vascular injuries. The most superficial fascia is located just below the skin, superficial to the platysma muscle.
The platysma muscle, which originates in the upper chest, extends superiorly over the clavicles and covers the
anterolateral neck before attaching to the lower facial muscles. Documentation of platysmal violation and zone
of injury is essential when evaluating patients with PNI. When the platysma is violated, a careful search for
aerodigestive and neurovascular injury must be performed.
Deep to the platysma is the deep cervical fascia. This divides into prevertebral, pretracheal, and investing
layers. The pretracheal fascia attaches to the cartilaginous structures in the anterior neck (cricoid and larynx)
before coursing inferiorly and deep to the sternum, ultimately inserting onto the sternum and pericardium. The
location of this fascia allows spillage of contents from an injured esophagus into the mediastinum. The carotid
sheath is composed of all three layers of the deep cervical fascia. Within this sheath lie the carotid artery,
internal jugular vein, and vagus nerve [17]. One sheath lies lateral to each side of the midline trachea. The
esophagus is directly posterior to the trachea.
MECHANISM Penetrating neck injuries commonly occur from guns, knives, and other impaling objects.
Gunshot wounds are further divided into high and low velocity injuries. Bone penetration requires a velocity of
approximately 350 feet per second (107 meters per second). Because low velocity weapons (eg, 22-caliber
guns, other handguns, air guns) do not typically penetrate bone, they tend to produce a more erratic path
through soft tissue, following tissue planes. Military weapons and hunting rifles can fire at speeds over 2000 to
3000 feet per second (610 to 910 meters per second) and follow a more direct, predictable course through bone
and soft tissue. High velocity weapons can cause injury far from the bullet track through the release of high
energy with impact (ie, blast effect). Clinicians may underestimate tissue damage from this effect [18].
PREHOSPITAL CARE
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General management Any patient with a penetrating neck injury (PNI) can decompensate rapidly and
should be transported immediately to the nearest trauma center. These patients often require emergency
surgical intervention. Impaled objects should NOT be removed in the field. General prehospital management of
the trauma patient is discussed elsewhere. (See "Prehospital care of the adult trauma patient".)
Airway management in the patient with PNI can be difficult, and is discussed in detail below. (See 'Airway
management' below.) Orotracheal intubation is the primary approach to airway stabilization when a definitive
airway is required immediately. Bag mask ventilation (BMV) can be used during transport. BMV can become
problematic, however, if an airway injury is present. BMV can force air into soft tissue planes leading to
anatomical distortion.
During transport, breath sounds should be auscultated and vital signs assessed frequently. Hypotension,
tachypnea, unilaterally diminished breath sounds, and subcutaneous emphysema raise suspicion for a tension
pneumothorax. Paramedics should perform needle thoracostomy if the patient is unstable and tension
pneumothorax is suspected.
In general, patients should be allowed to assume a position that enables them to breathe. This is particularly
true if hemorrhage is extensive and creates breathing difficulty.
Place a large bore IV (eg, 14 gauge) in the arm opposite the injury if possible and control active bleeding with
direct pressure. Patients with bubbling or sucking neck wounds should ideally be placed head-down (eg,
Trendelenburg position) on their left side to prevent potential vascular air embolism. Gauze impregnated with
petroleum jelly should be applied to the wound to prevent venous air embolus.
Cervical spine immobilization Cervical spine (C-spine) immobilization should be applied if clinical findings
(eg, hemiplegia) suggest spinal cord injury. However, such injuries are uncommon with penetrating neck trauma
(particularly stab wounds) and immobilization may hinder management in some cases by impeding visualization
of the airway or obscuring other injuries [14,19-22].
We agree with the practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) which
state that C-spine immobilization is only necessary when a neurologic deficit is present or a proper physical
examination cannot be performed (eg, unconscious patient) [23]. A systematic review performed by the
Prehospital Trauma Life Support Program concurs with this approach and goes on to emphasize that spine
immobilization must not be performed at the expense of an accurate examination or the treatment of lifethreatening conditions in a patient with penetrating trauma [24]. Patients in need of C-spine immobilization who
have difficulty breathing due to hemorrhage may need their stretcher placed on its side, or may need to sit
upright while C-spine precautions are maintained as best as possible.
CLINICAL FEATURES
Laryngotracheal injuries Laryngotracheal injuries are predominantly confined to the cervical trachea. Such
injuries can result in respiratory distress, stridor, subcutaneous air, hemoptysis, odynophagia, dysphonia, or
anterior neck tenderness.
Vascular injuries Vascular injuries can involve the carotid artery (common, internal, and external), the
subclavian and vertebral arteries, and the vertebral, brachiocephalic, and jugular (internal and external) veins.
Vascular wounds are not always obvious and if missed may lead to delayed complications, such as delayed
rupture and arteriovenous fistula. Look for obvious and subtle signs of injury. Obvious signs include severe
bleeding, decreased or absent peripheral pulses, global or focal neurologic deficits (eg, stroke), expanding
hematoma, and bruits or thrills. Subtle signs include nonexpansile hematomas, mild bleeding, and transient
hypotension that respond to fluid resuscitation. Intact pulses do NOT negate the possibility of vascular injury.
Global neurologic deficits (eg, hemiplegia) can be caused by a vascular injury. A patient with a normal physical
examination who is otherwise asymptomatic is unlikely to have sustained a surgical vascular lesion [25].
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Pharyngoesophageal injuries Pharyngoesophageal injuries are uncommon but are associated with high
morbidity and mortality [11,13]. They can be difficult to detect clinically and appear to be the leading cause of
delayed death from neck trauma [23,26,27]. Clinicians should aggressively search for pharyngoesophageal
injuries in patients with any suggestive signs using appropriate ancillary studies. There are no pathognomonic
signs of esophageal injury, but dysphagia, blood in the saliva, hematemesis, and subcutaneous air suggest the
diagnosis [27]. (See 'Emergency management' below.)
Nervous system injuries Penetrating neck injury (PNI) can involve the central nervous system (spinal cord)
or the peripheral nervous system (cranial nerves including VII though XII, sympathetic chain, peripheral nerve
roots, brachial plexus). Spinal cord injury is uncommon following low velocity PNI (eg, stabbing). (See 'Cervical
spine immobilization' above.)
High spinal cord injury can result in neurogenic shock with hypotension and bradycardia. Partial cord lesions
create variable combinations of motor and sensory deficits depending on the lesion. The Brown-Sequard
syndrome (lateral hemisection of the spinal cord) results in ipsilateral hemiplegia and contralateral loss of pain
and temperature sensation. Hemiplegia occurs at the level of the injury while the sensory deficits occur one to
two levels superiorly. Injury to the anterior spinal cord produces bilateral paralysis or motor deficits of variable
severity, reflex changes, and bilateral loss of pain and temperature sensation, but proprioception is preserved.
Dorsal spinal cord injury produces muscle flaccidity, hyporeflexia, ataxia, and loss of proprioception.
Peripheral or cranial nerve (CN) injuries may not be obvious unless a careful neurologic examination is
performed. If possible, assess the patient's speech (CN IX, X, XII), movement of the palate (CN IX, X) and
tongue (CN XII), and shoulder shrug (CN XI). These functions involve the cranial nerves most frequently
injured.
Horner's syndrome occurs with injury to the sympathetic chain, and produces ipsilateral miosis with ptosis of the
upper eyelid and anhidrosis of the ipsilateral side of the face. It is seen most commonly with zone I injuries.
EMERGENCY MANAGEMENT
Initial evaluation and interventions Patients with penetrating neck injury (PNI) may appear stable but can
decompensate rapidly. Surgical consultation should be obtained for all PNIs unless the wounds are determined
to be superficial. An algorithm for wounds that penetrate the platysma is provided (algorithm 1).
Penetrating neck trauma must be approached systematically. Immediately assess the airway of any patient with
PNI. Assessment can be difficult, particularly deciding whether the patient needs early intubation. Although no
consensus exists, most experts advocate immediate intubation in patients with evidence of significant injury or
respiratory difficulty (eg, subcutaneous air, airway compromise, significant bleeding or hematoma, voice
alteration, stridor) [28-31]. (See 'Airway management' below.)
Once the airway has been stabilized, inspect and auscultate the chest. Zone I injuries can cause damage to
intrathoracic structures (eg, lung). Moreover, multiple zones may be involved, creating injuries in both the neck
and chest. Unilaterally decreased breath sounds or palpable subcutaneous emphysema suggests
pneumothorax. The neck zones are defined above.
Next, assess pulses and vital signs. Apply direct pressure to bleeding wounds. In almost all cases, the wound
should not be explored in the emergency department (ED). For persistent, life-threatening bleeding from a neck
wound that does not stop with direct pressure, the clinician can insert a Foley catheter into the wound and fill
the balloon with 10 to 15 mL of saline or until resistance is felt [32-34]. This may temporarily tamponade
bleeding until definitive treatment is available. If bleeding is severe, neither direct pressure nor a Foley catheter
effectively controls the hemorrhage, and no surgeon is available, the emergency clinician may have no choice
but to attempt to explore the wound and control bleeding by other means (eg, placing a clamp).
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Place patients on a cardiac monitor and pulse oximetry, and provide supplemental oxygen. Place two large
bore (eg, 14 gauge) IV lines. The IV lines should be placed contralateral to the injury if possible because
ipsilateral venous injuries may exist.
Type and cross-match blood in preparation for transfusion and obtain blood samples for testing. The blood tests
to obtain vary with clinical circumstance, but usually include:
Prothrombin time (PT) with international normalized ratio (INR) and activated partial thromboplastin time
(PTT)
Serial hemoglobins
Blood urea nitrogen and serum creatinine and electrolytes
Traumatic arrest in the ED in a patient with a PNI is an indication for emergency thoracotomy. Potential causes
of arrest include hemorrhagic shock, tension pneumothorax, airway compromise, and air embolism. ED
thoracotomy is discussed separately. (See "Initial evaluation and management of shock in adult trauma".)
Unstable patients with active hemorrhage are managed in the operating room. Those with findings suggestive
of major injury require further evaluation, which may include angiography with embolization. They may be taken
to the angiography suite, operating room, or intensive care unit (ICU). Stable patients with less obvious signs of
injury are often evaluated further in the ED. The signs of injury are described above. (See 'Clinical features'
above.)
Stable patients should be closely monitored throughout their evaluation. Perform frequent reexaminations and
look closely for signs of injury to the larynx, trachea, pharynx, esophagus, carotid arteries, jugular veins, lower
cranial nerves, brachial plexus, and spinal cord.
Although careful physical examination identifies most arterial wounds, it does not detect some important
injuries, particularly those of the esophagus. Venous injuries can also be missed. Left neck trauma can rarely
involve the thoracic duct. Although uncommon, the thyroid gland can be injured, as can other submandibular
glands. Lower neck wounds can cause injury to thoracic structures, including the aorta, a mainstem bronchus,
and the lungs. Clinicians should perform diagnostic imaging if there is the slightest concern about occult injury.
A careful primary and secondary trauma survey should be performed looking for other injuries. Consider
concomitant injuries as a source of patient distress. Perform a careful neurologic examination looking for gross
deficits and less obvious signs of cranial or peripheral nerve injury. General assessment of the trauma patient is
discussed separately. (See "Initial management of trauma in adults".)
Airway management Direct injury to the airway or the neck may require immediate airway protection.
Airway management in these patients can be difficult. A systematic approach is needed, and must address the
following questions (algorithm 2):
Does the patient require emergent airway protection?
What is the best approach and technique for airway protection?
Patients with penetrating neck injury (PNI) in obvious distress (eg, respiratory distress, severe hemorrhage,
extensive or sucking neck wound, shock) require immediate stabilization of the airway. Other patients with neck
trauma may require airway protection based on the projected course of their disease. A general discussion of
how to approach the difficult airway is discussed separately. (See "The difficult airway in adults".)
Signs that strongly suggest the need to secure the airway emergently include:
Significant bleeding or hematoma
Hemoptysis
Subcutaneous emphysema
Bruit or thrill
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Neurologic deficit
Distorted neck anatomy
Stridor
Difficulty or pain when swallowing secretions
Abnormal voice, especially hoarseness ("hot potato voice")
When the airway is felt to be threatened but anatomic structures and relationships are preserved, rapid
sequence intubation (RSI) is appropriate to establish an airway [20,35,36]. One retrospective review of airway
management in patients with PNI performed at a major urban trauma center found RSI to be a safe and
effective approach [36]. Other centers have found similar results [37]. In-line stabilization of the cervical spine
by an assistant is indicated if spinal injury is suspected, although spine injuries are uncommon with PNI.
Rescue airway devices (eg, laryngeal mask airway) can be used if placement of an endotracheal tube is
unsuccessful as long this does not delay the establishment of a needed surgical airway. (See "Rapid sequence
intubation in adults" and 'Cervical spine immobilization' above.)
RSI should not be used and a surgical airway is recommended if significant trauma or obstruction above the
larynx is likely to preclude successful placement of an endotracheal tube (ETT), or if anatomy is sufficiently
distorted that the normal anterior surface landmarks of the airway cannot be identified. Neuromuscular paralysis
is often unnecessary when penetrating injury causes partial or complete transection and exposure of the
trachea. In these cases, the caudad portion of the exposed trachea can be stabilized with a towel clip or clamp
and intubated directly.
If endotracheal intubation is deemed necessary in an initially stable patient, based upon the projected course of
injury, and the airway is predicted to be difficult because of distorted anatomy, the clinician may elect to use an
"awake look" approach via laryngoscopy. This approach entails giving the patient procedural sedation and
topical anesthesia to enable direct or fiberoptic laryngoscopy and intubation, if conditions are favorable. When
direct airway injury is suspected (eg, subcutaneous air is present in the soft tissues of the neck), a fiberoptic
guided oral intubation may be the best approach, if available, because it enables the clinician to determine the
integrity of the interior of the airway above and below the vocal cords [38]. The awake look approach is
discussed separately. (See "The difficult airway in adults", section on 'Awake technique'.)
We recommend simultaneous preparation for RSI and a surgical airway (ie, double set-up) if an "awake look"
approach is used. Some clinicians suggest avoiding an "awake look" approach because of concerns that it can
precipitate airway collapse. However, this assertion is unproven.
The best method to achieve definitive airway control in the setting of PNI may vary according to clinical
circumstances, clinician skill, and hospital resources [39]. Nevertheless, the following concepts generally apply:
Avoid techniques not performed under direct or fiberoptic visualization. Blind placement of an ETT into a
lacerated tracheal segment can create a false lumen outside the trachea or convert a partial tracheal
laceration into a complete transection.
Be prepared for unexpected difficulty. Have available and ready for use two suction devices, a range of
different sized ETTs, rescue airway devices, and a surgical airway kit. We recommend a double set-up for
patients with PNI in whom orotracheal intubation is attempted. Patients with neck trauma can deteriorate
quickly and may have abnormalities that complicate ETT placement but are not apparent externally.
Bag mask ventilation (BMV) to preoxygenate in preparation for RSI or to reoxygenate following a failed
attempt at intubation may force air into injured tissue planes and distort airway anatomy. Although it is
appropriate to perform BMV to oxygenate patients when necessary, ventilation should be done as gently
as necessary, and with vigilance to ensure it is not creating more harm than benefit.
Invasive airway management (eg, cricothyroidotomy) represents the standard approach when orotracheal
intubation, by any method, is unsuccessful or contraindicated. Indications for a surgical airway include massive
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upper airway distortion, massive midface trauma, and inability to visualize the glottis because of heavy
bleeding, edema, or anatomic disruption. (See "Emergency surgical cricothyrotomy (cricothyroidotomy)".)
Cricothyrotomy can be difficult in a patient with anatomical distortion. The procedure is relatively contraindicated
if an anterior neck hematoma exists or a laryngeal injury is suspected, but may be the only option in some
patients with PNI. If the necessary resources and expertise are readily available, patients whose external
landmarks are sufficiently distorted to make cricothyrotomy difficult or impossible are generally intubated awake
using a flexible fiberoptic intubating scope. If the clinician suspects partial or complete laryngeal transection, a
fiberoptic approach or a tracheostomy inferior to the injury may be necessary.
Percutaneous needle transtracheal or cricothyroid jet ventilation can provide oxygen to adult and pediatric
patients while arrangements are made to establish a definitive airway. Clinicians must take care to avoid
catheter misplacement or dislodgement, which can force air into the tissues and distort normal airway anatomy.
There is no evidence to support the use of percutaneous oxygenation in patients with PNI, and the technique is
best reserved for small children in whom formal cricothyroidotomy is difficult or impossible. (See "Needle
cricothyroidotomy with percutaneous transtracheal ventilation".)
Blind nasotracheal intubation (BNI) should not be attempted in these patients. BNI can exacerbate preexisting
airway injury. It can also cause vomiting and aspiration, turbinate injury, elevated intracranial pressure,
bleeding, and in awake patients, cervical spine motion from discomfort [40].
Diagnostic evaluation
General approach Patients with unstable penetrating neck injuries (PNI) are resuscitated with emphasis
upon rapid stabilization of the airway, breathing, and circulation (ABCs) as described above. Such patients are
brought to the operating suite expeditiously and diagnostic testing is performed there. (See 'Initial evaluation
and interventions' above and 'Airway management' above.)
Stable patients with PNI must be monitored closely, as described above, while diagnostic evaluation proceeds.
Clinicians must remain alert for delayed presentations of airway compromise or other injuries. Multiple studies
suggest that asymptomatic patients with PNI can be managed nonoperatively. Therefore, the emergency
clinician often initiates the search for injuries to the pulmonary, vascular, digestive, and neurological systems,
following the initial trauma evaluation. Although careful physical examination identifies most arterial wounds, it
does not detect some important injuries, particularly those to the esophagus. Venous injuries can also be
missed. Clinicians should perform diagnostic imaging if there is any reasonable suspicion for occult injury. The
work-up for specific injuries is discussed below.
No consensus exists about the role of physical examination to detect surgical injuries; most trauma specialists
use ancillary testing but a small minority continues to advocate mandatory surgical exploration. At remote
community hospitals and nontrauma centers, mandatory surgical exploration of Zone II injuries may be
performed to avoid missing an injury that would otherwise present in delayed fashion when emergent treatment
could not be provided. However, even in areas with limited trauma services, a more selective approach to
surgical exploration may be reasonable [41]. (See 'Definitive management' below.)
Physical examination Whether physical examination can reliably detect significant visceral or vascular
injuries from penetrating neck trauma remains a source of debate. Two prospective studies underscore this
difference of opinion. The first evaluated 393 consecutive patients with PNI and found that 30 percent had
significant injuries discovered during surgical neck exploration despite no evidence of such injury during the
initial examination [3]. In contrast, a second study of 223 patients with PNI concluded that careful examination
using a written protocol that identified objective signs of injury (eg, large expanding hematomas, severe active
bleeding, shock not responding to fluids, diminished radial pulse, bruit) reliably predicted major vascular
trauma requiring treatment [7].
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A number of retrospective observational studies suggest physical examination may be most accurate for
determining the presence of arterial injury [42-45]. Similar studies suggest physical examination is least
accurate at detecting esophageal injury [23,46,47]. Venous injuries may also be difficult to detect. Additional
prospective trials and follow-up studies are needed.
Diagnostic studies overview Although many trauma specialists advocate computed tomography with
angiography (CT-A) for the evaluation of stable patients with PNI, no consensus exists as to the best diagnostic
approach, and practice varies based upon institutional resources and protocols, the most likely injuries, and
local surgical practice [23,48-52].
If aerodigestive injury is suspected, CT alone or in conjunction with esophageal studies (contrast swallow and
endoscopy) provides an accurate diagnosis in most cases. Esophageal injury can be difficult to diagnose and
no "gold standard" for testing has been established. Suspicion for vascular injury prompts vascular studies
which vary by institution. Options include CT-A and color-flow Doppler ultrasound (CFD). CT-A is sensitive for
vascular injury and generally available [53]. Conventional angiography may be needed if metallic debris
obscures bullet trajectory and anatomic detail. CFD is increasingly used, but is operator-dependent and not
always available. Studies other than CT-A are generally best performed in consultation with the trauma surgeon
to ensure an appropriate and efficient work-up. As an example, some surgeons prefer bronchoscopy for Zone I
injuries.
Laryngotracheal injury Some laryngotracheal (LT) injuries are obvious, while others require diagnostic
imaging. Multidetector helical CT (MDCT) is the tool used most often to screen for these injuries in stable
patients. MDCT provides anatomic detail about laryngeal integrity and is useful when cervical spine
immobilization is necessary [54-56]. MDCT provides better images of mineralized cartilage than plain
radiographs.
MDCT has some limitations. Degloving injury of the cartilage with denuded mucosa can be missed, as can
certain types of LT separation and mucosal perforation. Pediatric cartilaginous structures are poorly calcified
and may be more difficult to visualize than an adult larynx. Typically, injuries missed by MDCT do not require
operative repair, such as minor edema, hematoma, minor denuded cartilage, and non-displaced fractures [57].
Further studies may be necessary in patients with clinical signs of injury or at high risk for occult injury whose
initial imaging is nondiagnostic. Endoscopy or laryngoscopy provides alternatives for the diagnosis of LT
trauma, and is preferred in some hospitals [56,58]. Endoscopy enables thorough evaluation when scatter
artifact from metallic objects obscures CT images.
Flexible nasopharyngoscopy allows visualization of the hypopharynx and supralaryngeal structures in an awake
or sedated patient, while flexible laryngoscopy allows evaluation of more distal structures. Rigid endoscopy
allows for evaluation of the distal airway, but requires general anesthesia.
Vascular injury Some controversy remains about the best way to assess for vascular injury in stable
patients with PNI. The preferred diagnostic study varies by hospital and selection should be made in
consultation with the trauma surgeon.
In most trauma centers, multidetector helical CT scan with angiography (CT-A) has replaced conventional
angiography for the evaluation of vascular injury in PNI [48,59]. The sensitivity and specificity of CT-A for
detecting significant vascular wounds in the neck approaches that of standard angiography [48,60,61]. Other
benefits of CT-A include wide availability, detection of nonvascular injuries, and speed. The entire neck can be
scanned in under five minutes, and the head and chest can also be studied when necessary.
Angiography demonstrates sensitivity and specificity of close to 100 percent and has been considered the gold
standard in stable patients for decades [6]. It may be the best study to diagnose certain vascular injuries,
especially if procedures such as embolization or stent placement are anticipated or when artifacts obscure CT
images of the vasculature. Suspected distal carotid artery lesions may be better assessed using angiography
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as less invasive studies have limitations in that region. Some have argued that arteriography enables better
surgical planning, but this concept is largely obsolete [6,60,62,63].
Two or four vessel angiography is costly, invasive (complications occur in approximately 2 percent of patients),
and consumes a great deal of resources. These factors combined with the high number of negative studies
have led many trauma specialists to use noninvasive tests coupled with careful physical examination for the
initial evaluation of possible vascular neck injuries [7,64,65].
If chosen, angiography should include the carotid and vertebral vessels, the intracranial portion of the carotid
artery in zone III injuries, and the aortic arch with its branches in zone I injuries.
Color flow Doppler ultrasound (CFD) in combination with a careful physical examination can detect or suggest
the presence of vascular injury and may represent an alternative to angiography in select patients [62,66,67].
According to one prospective study, CFD and careful physical examination are 100 percent sensitive and
specific compared with conventional angiography at detecting vascular injury that requires surgical repair [68].
CFD is fast, noninvasive, and inexpensive.
CFD has limitations, including an inability to image the distal intracranial portions of the carotid artery and
portions of the vertebral artery and the proximal subclavian vessels. In addition, CFD may not accurately detect
pseudoaneurysms and artifact (eg, from bony fractures, metallic foreign bodies, subcutaneous air) can obscure
vascular structures. The quality of CFD studies depends upon operator skill.
MR angiogram is not a first-line study to detect vascular injury following penetrating neck trauma. There are no
large, prospective studies comparing MRI to angiography. MRI has several drawbacks, including lack of
availability and longer scan time. Monitoring of the patient is difficult during the performance of an MRI.
Pharyngoesophageal injury Debate continues about the best management strategy for identifying
pharyngoesophageal injuries following penetrating neck injury (PNI). More trauma centers are using a selective
approach to surgical exploration. This can delay the detection of esophageal injury and such delays can
increase mortality [27]. Furthermore, debate persists about whether esophageal injuries requiring surgery
manifest obvious clinical findings [27,69]. Given the potential difficulties in diagnosis and the consequence of
delays, many trauma specialists obtain imaging studies to rule out esophageal injury in all cases of
nonsuperficial PNI. A multidetector helical CT scan (MDCT) is often the first study obtained because it can
detect laryngotracheal, vascular, and esophageal injuries simultaneously and rapidly.
A plain neck or chest radiograph showing retropharyngeal air or pneumomediastinum, respectively, suggests
esophageal injury, but neither test is specific [70]. In such cases, immediate surgical consultation is obtained to
determine management and the choice of further imaging, should the patient not proceed immediately to the
operating suite.
MDCT imaging is often obtained in a patient with a zone I injury or soft signs of esophageal injury (eg,
dysphagia). Evidence of a wound in close proximity to the esophagus or a nondiagnostic study in a patient with
soft signs of injury necessitates immediate surgical consultation to determine further testing, which may include
esophagography or endoscopy. Others may opt for surgical exploration.
MDCT is used increasingly to assess patients with PNI. One prospective observational study found MDCT to
have high sensitivity and specificity for aerodigestive injuries [71]. Another prospective study suggested that
MDCT may lack sensitivity for detecting esophageal injuries [47]. Additional trials are needed to determine the
test's accuracy.
Practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) suggest that either
endoscopy of the esophagus or esophagography can be used to rule out significant esophageal injury in
patients with PNI [23]. However, studies of these techniques in this patient population are small and both
approaches have limitations. Flexible endoscopy does not require general anesthesia, but can miss proximal
esophageal injuries if views are inadequate. However, according to one small retrospective study, flexible
Page 10 of 20
endoscopy demonstrates high sensitivity for penetrating esophageal injury [72]. Rigid endoscopy exposes
awake patients to the risks of general anesthesia and may be complicated by perforation. Scatter artifact from
metallic objects may obscure CT images. In such cases, either form of endoscopy is preferred.
The sensitivity of simple contrast studies (ie, esophagography) for esophageal injury is approximately 80 to 89
percent [4,26]. These studies require patient cooperation to obtain adequate views. Some believe
esophagography is an adequate screening tool if clinical suspicion for esophageal injury is low [5,73]. One
study found the combination of esophagography and flexible endoscopy to be 100 percent sensitive for
detecting esophageal injury [26]. Another group found that among stable patients lacking hard signs
of aerodigestive injury, endoscopy provided no additional information compared to MDCT scan alone [74]. They
propose performing endoscopy in addition to MDCT only in patients who are symptomatic but lack clear
indications for emergent operative exploration.
DEFINITIVE MANAGEMENT
Consultation and disposition Patients with PNI can be categorized as unstable with signs reflecting severe
injury (eg, stroke, airway obstruction, shock), stable with soft signs or symptoms suggesting injury (eg,
dysphagia, nonexpanding hematoma, minor bleeding), or asymptomatic.
Unstable patients and those with hard signs of significant injury are taken emergently to the operating room for
definitive treatment [23,52]. Asymptomatic patients can generally be observed and evaluated with serial
physical examinations or institution-specific protocols involving ancillary studies. We generally obtain immediate
surgical consultation for all cases of nonsuperficial penetrating neck injury (PNI) and place the asymptomatic
patient in a monitored setting with close observation.
Controversy arises with the management of stable PNI patients manifesting soft signs of injury. Computed
tomography with angiography (CT-A) is a powerful tool and the initial study of choice for most of these patients
[50,52]. Additional testing can be based upon CT-A findings. As an example, a high (zone III) vascular lesion
evident on CT-A may mandate conventional angiography and stent placement. If the CT-A is indeterminate for
aerodigestive tract injury (eg, CT reading is: air bubbles seen; cannot exclude aerodigestive injury), further
evaluation (eg, esophagography, endoscopy) is indicated.
Management varies according to clinical circumstance, local surgical practice, and hospital resources. We
recommend transfer to a trauma center for any patient at risk for significant injury.
Mandatory versus selective surgical management The management of PNI, particularly in stable
patients, remains a source of debate among trauma surgeons. The primary controversy is whether all such
patients require surgical exploration, especially for zone II injuries, or whether selected patients can be
managed nonoperatively. Most research and many trauma surgeons favor some form of selective
management. One early review concluded that zone II injuries have similar outcomes regardless of whether
they undergo mandatory surgery or selective management, while subsequent research supports a selective
approach [4,10,34,71]. Practice guidelines from the Eastern Association for the Surgery of Trauma (EAST)
state that both approaches are justifiable and safe [23].
No consensus exists about the role of physical examination to detect surgical injuries; most trauma specialists
use ancillary testing but some continue to advocate mandatory surgical exploration [64,75-79]. At community
hospitals and nontrauma centers, close serial examinations are not always possible and mandatory surgical
exploration may be necessary to avoid missing an injury that would otherwise present in delayed fashion, when
emergent treatment could not be provided.
Advocates for mandatory surgery with zone II injuries believe the relative ease of access to this region makes
injuries more amenable to surgical repair and thus, regardless of hemodynamic stability or signs of injury, all
patients should be managed in the operating room. The proponents of a selective approach believe the
Page 11 of 20
multitude of diagnostic options, ranging from angiography and esophagoscopy to serial examinations without
ancillary studies, allows for safe nonoperative management while avoiding unnecessary procedures.
Debate continues about the best approach (mandatory versus selective surgery) for injuries in zones I and III.
However, the selective approach has gained popularity over the past decade.
Specific injuries
Laryngotracheal injury A large proportion of patients with traumatic airway injuries require definitive
airways [80,81]. Endotracheal intubation using rapid sequence intubation (RSI) is safe in the majority of
patients, although exceptions exist [36]. Airway management is discussed in detail above. (See 'Airway
management' above.)
Timely repair of certain laryngotracheal injuries is important to prevent long-term complications such as
chronic pain, stenosis, or voice change.
Pharyngoesophageal injuries Obtain surgical consultation for all suspected pharyngoesophageal
injury (PEI). Most PEIs are treated surgically, but select patients may be managed nonoperatively [5].
If not promptly diagnosed, PEI can cause mediastinitis and abscess or empyema formation from the
leakage of gastric contents. Clinicians should begin treatment with broad-spectrum antibiotics in all
patients with possible PEI. Although some trauma specialists advocate decompressing the stomach with a
nasogastric tube, performing a blind procedure in a patient with PEI entails significant risk [2]. We do not
believe this procedure should be performed blindly in the emergency department.
Vascular injuries Obtain immediate consultation with a vascular surgeon if vascular injury from a PNI is
suspected. A trauma or thoracic surgeon may be needed and should be consulted if a zone I vascular
injury is suspected.
A range of surgical and interventional options exist for the management of vascular injury, including
embolization, ligation, stent placement, surgical repair, and revascularization. Early revascularization
offers the best chance for successful outcome when managing injuries to the carotid artery [2,6,82,83].
Coma portends a poor outcome. Inability initially to differentiate coma due to neurologic insult from coma
due to drug or alcohol abuse can confuse the clinical picture and management options.
Neurological injuries Cervical spine injury is uncommon following penetrating trauma to the neck. A
retrospective review of a large trauma database found the incidence of cervical spine fracture to be 1.35
percent with gunshot wounds and 0.12 percent with stab wounds to the neck. The incidence of spinal cord
injury was even lower. All patients with cervical spinal cord injury had a neurologic deficit at initial
presentation. MDCT and possibly MRI are useful for the diagnosis of these injuries [19].
Pitfalls and pearls
Concentrate on imminent and delayed signs of airway compromise. Do not allow dramatic thoracic injuries
to distract from essential airway management.
Be prepared to provide a surgical airway immediately if attempts at oral intubation fail. Use a double setup.
Wounds to the distal carotid artery can cause neurological deficits that mimic stroke, spinal cord, or head
injury.
Zone I injuries can involve life-threatening thoracic injuries.
Maintain high concern for occult esophageal injuries, which can cause life-threatening sequela.
Page 12 of 20
Never delay surgical consultation.

SUMMARY AND RECOMMENDATIONS
Mortality in patients with penetrating neck injury (PNI) appears to be highest with zone I injuries (below the
cricoid cartilage) (figure 1). Clinical neck anatomy is described above. (See 'Epidemiology' above and
'Anatomy' above.)
Any patient with a PNI can decompensate rapidly and should be transported immediately to the nearest
trauma center if possible. Standard prehospital trauma care is provided. Impaled objects should NOT be
removed in the field. Bag mask ventilation (BMV) can become problematic if an airway injury is present
and air is forced into soft tissue planes leading to anatomical distortion. Cervical spine injury from PNI is
uncommon and immobilization is not necessary in many instances. (See 'Prehospital care' above.)
Patients with PNI in obvious distress (eg, respiratory distress, severe hemorrhage, extensive or sucking
neck wound, shock) require immediate stabilization of the airway. Initially stable PNI patients may require
airway protection based on the projected course of their disease. Signs that strongly suggest the need to
secure the airway emergently include:
Significant bleeding or hematoma
Hemoptysis
Subcutaneous emphysema
Bruit or thrill
Neurologic deficit
Distorted neck anatomy
Stridor
Difficulty or pain when swallowing secretions
Abnormal voice, especially hoarseness ("hot potato voice") (see 'Airway management' above).
In most cases of PNI, rapid sequence intubation (RSI) can be used to establish an airway when
necessary. Intubation should be performed under direct laryngoscopic or fiberoptic visualization. Be ready
for unexpected difficulty; prepare simultaneously for orotracheal and surgical airway management (ie,
double set-up). (See 'Airway management' above.)
Initial management of patients with PNI follows standard trauma protocols. Special considerations in PNI
include the following: Zone I neck injuries can involve intrathoracic structures. Traumatic arrest in the
emergency department (ED) is an indication for emergency thoracotomy if feasible in patients with PNI.
Do NOT explore neck wounds in the ED. Obtain emergency surgical consultation for all PNIs, aside from
obviously superficial injuries. (See 'Initial evaluation and interventions' above.)
Unstable patients with PNI receive definitive care in the operating suite. Stable patients often require
additional imaging studies and observation in a monitored setting. Stable patients at nontrauma centers
with concerning symptoms or signs should be transferred to a trauma center if definitive care cannot be
provided.
Careful physical examination identifies most arterial wounds, but can miss important esophageal and
venous injuries. In general, additional evaluation (eg, CT, esophagoscopy) is necessary for any PNI that
violates the platysmas.
Page 13 of 20
Laryngotracheal injuries can result in respiratory distress, stridor, subcutaneous air, hemoptysis,
odynophagia, dysphonia, or anterior neck tenderness. Signs of vascular injury include significant bleeding
or hematoma, decreased or absent peripheral pulses, global or focal neurologic deficits (eg, stroke), and
bruits or thrills. Intact pulses do NOT rule out vascular injury. (See 'Laryngotracheal injuries' above and
'Vascular injuries' above.)
Pharyngoesophageal injuries are uncommon and often occult but are associated with high morbidity and
mortality. Clinicians should aggressively search for pharyngoesophageal injuries in patients with any
suggestive signs. These may include dysphagia, blood in the saliva, hematemesis, and subcutaneous air.
(See 'Pharyngoesophageal injuries' above.)
Penetrating neck injury can involve the central nervous system (spinal cord) or the peripheral nervous
system (cranial nerves including VII though XII, sympathetic chain, peripheral nerve roots, brachial
plexus). Specific injuries are described in the text. (See 'Nervous system injuries' above.)
Although many trauma specialists advocate computed tomography with angiography (CT-A) for the
evaluation of stable patients with PNI, no consensus exists as to the best diagnostic approach, and
practice varies based upon institutional resources and protocols, the most likely injuries, and local surgical
practice. The relative advantages and disadvantages of available tests for specific injuries are discussed
in the text. (See 'Emergency management' above.)
Most research supports selective operative management of stable patients with PNI. Controversy
surrounds the indications for mandatory surgical exploration, particularly with zone II injuries. Definitive
management of stable patients with PNI varies by institution and local surgical practice. (See 'Mandatory
versus selective surgical management' above.)
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Topic 355 Version 21.0
Page 17 of 20
GRAPHICS
Zones of the neck
Graphic 52642 Version 2.0
Page 18 of 20
Anatomical regions of the neck
Page 19 of 20
Algorithm for penetrating neck injury through the

platysma
CXR: chest x-ray; MDCT-A: multidetector computed tomography with angiography;

OR: operating room.
* Preferred imaging studies vary by institution and local expertise.
Page 20 of 20
Algorithm for management of traumatized airway
RSI: rapid sequence intubation; SaO 2 : arterial oxygen saturation; TTJV: transtracheal jet
ventilation.
Disclosures
Disclosures: Kim Newton, MD Nothing to disclose. Maria E Moreira, MD Nothing to disclose. Richard G Bachur, MD Nothing to
disclose. Jonathan Grayzel, MD, FAAEM Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
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