This document discusses neck trauma, focusing on evaluation and management in the emergency department. It divides the neck into 3 zones based on anatomical structures. Zone I injuries carry the highest risk but are difficult to access. Zone II injuries are most common and can often be explored surgically with low morbidity. Zone III injuries are also surgically challenging. Evaluation may involve imaging like C-spine films, CT, or angiography. Unstable patients generally require immediate surgery. Stable patients can often be managed with selective diagnostic tests to determine if surgery is needed.

1. Neck Trauma

2. Neck Trauma
• Approximately 5-10% of traumatic injuries involve the neck.
• The most critical and immediately life-threatening problem is
– airway obstruction and massive hemorrhage.
• Approximately 3,500 people die each year from neck trauma
due to
– suicides, hangings and accidents.
• Most blunt trauma is caused by MVA
– driver hitting the steering wheel or dashboard
– commonly resulting in laryngotracheal injuries.

3. Neck Trauma
• Critical Landmarks
– A determination should be made as to
whether or not the platysma muscle has
been violated.
– Platysmal violation is often a clue to damage
and injury to deeper structures.
– the neck is divided into three anatomic
zones
• In order to properly evaluate, diagnose
and prioritize neck injuries,

4. • Zone I
– is bounded by the clavicles inferiorly and the cricoid cartilage
superiorly.
– contains many crucial structures including:
• the lung apices, trachea, aortic arch, the great vessels,
esophagus, cervical spine and spinal cord.
– Injuries in this zone are often
• difficult to access and repair and
• carry the highest morbidity and mortality risk.

5. • Zone II
– is bounded by the cricoid cartilage inferiorly and the angle of the
mandible superiorly.
– Crucial structures in this zone include:
• the trachea, larynx, esophagus, carotid arteries, jugular veins,
vertebral vessels, cervical spine and cord.
• This zone is easily surgically accessible, and an oblique neck
incision can often be used with minimal morbidity.

6. • Zone III
– is bounded by the angle of the mandible inferiorly and the base of
the skull superiorly.
– Structures in this zone include:
• the trachea, pharynx, esophagus, vertebral arteries, internal
carotid arteries and cranial nerves.
• Injuries in this region are surgically difficult secondary to
problems with obtaining proper exposure.

7. • Evaluation of Neck Trauma
– Early intubation is preferred for proper airway mgt.
– An expanding hematoma or laryngeal edema can occur quickly
causing airway compromise or occlusion leading to significant
morbidity.
– Neck wounds should NOT be explored in the ED due to the risk of
dislodging a clot and disrupting hemostasis.

8. • In patients with neck trauma, evaluation for arterial injury should be performed.
– The majority of injuries due to penetrating neck trauma are vascular injuries.
– The internal jugular vein and common and internal carotid artery are the vessels most frequently
injured with frequencies of 9% and 6.7%, respectively.
– Vertebral artery injury is rare. Typically, this lesion is clinically unsuspected and incidentally identified on
angiography.
– In hemodynamically stable patients, supportive and expectant mgt is advocated.
– Definitive Tx is required in patients with
• persistent bleeding,
• arteriovenous fistula formation or
• pseudoaneurysm.
– Clues to arterial injury include:
• expanding hematoma,
• pulsatile bleeding,
• shock unresponsive to fluids,
• presence of a new bruit or thrill,
• diminished distal pulses.
**Patients with the above findings often require immediate surgical intervention**
• A high index of suspicion should be maintained for esophageal injury secondary to blunt trauma.

9. • Diagnostic Studies
– Most patients require a three-view cervical spine series.
– Plain films can demonstrate
• SQ emphysema,
• fractures,
• tracheal deviation, and
• foreign bodies (e.g., bullet fragments).
– A chest X-ray is especially important to evaluate Zone I injuries since this region includes the
lung apices.
• A pneumothorax, hemothorax,
• SQ emphysema (due to an associated pneumothorax or injury to the larynx, trachea or esophagus),
• widened mediastinum (due to injury to a major mediastinal vessel) or foreign body may be visualized.
– Angiography is especially useful in evaluating Zone I and III injuries in hemodynamically stable
patients with platysmal violation.
• The use of color flow doppler is increasing since it is noninvasive and relatively inexpensive.

10. – However, this technique is operator dependent and its role in
assessing vascular injuries is still unclear.
– The CT scan is an important tool for diagnosing laryngeal injuries.
– The role of MRI in penetrating neck injuries is still being evaluated.
– Endoscopic evaluation of the trachea and/or esophagus should be
performed in patients at risk for injuries to these structures.
Esophagography (70-80% sensitivity) is important for evaluating
esophageal injuries; there is a 17% mortality rate after a 12 h delay
in diagnosis of esophageal injuries.

11. • ED Management
– Hemodynamic stability:
• Hemodynamically stable patients may undergo a diagnostic evaluation
depending on the zone involved and may not require surgical evaluation.
• However, hemodynamically unstable patients with neck injuries in any zone
require immediate surgical intervention.
– Zone I:
• angiography, esophagography or endoscopy (laryngoscopy or
bronchoscopy).
• If the result of any of the above studies is negative the patient is observed
and managed medically.
• If a study result is positive, surgical evaluation should be obtained.

12. – Zone II:
• There are two alternatives for evaluating penetrating Zone II injuries in a
hemodynamically stable patient.
• In the past, any injury with platysmal violation necessitated mandatory surgical
intervention.
• However, this approach is losing favor due to the high negative exploration rate;
many centers now favor selective mgt involving
• endoscopy, esophagography and angiography as indicated to determine the need
for surgical intervention.
– Zone III:
• Injuries in this zone are most commonly evaluated by a thorough oropharyngeal
examination, as well as laryngoscopy and angiography as indicated.