Penetrating neck injuries can involve important structures and require careful assessment and management. The document outlines: 1) A classification system for penetrating neck injuries based on location and depth. Zone I injuries below the cricoid cartilage pose the highest risk to major blood vessels. 2) A primary survey approach following ATLS guidelines is recommended to assess the airway, breathing, circulation, disability and environment. Hard signs of injury to airways or blood vessels require prompt surgical management. 3) Investigation may involve imaging like CT, Doppler ultrasound or angiography to identify injuries requiring surgery versus conservative management for stable patients with no signs of major injury. Early identification of injuries allows for proper treatment to prevent complications.

1. Penetrating neck injuries
Dr. Soe
Dr. Bhebhe
A&E
Family Medicine

2. Introduction
 Penetrating neck injuries are commonly
seen in South Africa. Although many are
minor injuries of no significance, they may
be deceptive in appearance.
 This presentation focuses on a logical
approach to the accurate assessment and
management of penetrating injuries to the
neck, excluding non-penetrating neck
injuries and injuries to the cervical spine.

3. Epidemiologic Features
 Firearms are responsible for approximately
44%, stab wounds for approximately 40%,
shotguns for approximately 4%, and other
weapons for approximately 12% of all
penetrating neck injuries in urban trauma
centers in the United States.
 Gunshot wounds are significantly more likely
to be associated with large neck hematomas,
hypotension on admission, and vascular or
aerodigestive injuries than knife wounds.

4. Mechanism of penetrating neck
injuries
 This type of injury may be the result of
interpersonal violence, for example, stab
or gunshot wounds, or accidents due to
foreign bodies, or iatrogenic incidents
during endoscopy or surgery.

5. Classification of penetrating neck
injuries
 A penetrating neck injury is one that has
penetrated platysma.
 Probing of the wound with a finger or an
instrument to determine the depth of the
wound is absolutely
contraindicated.

6. Classification of penetrating neck injuries
(cont)
Injuries penetrating the platysma should be
classified as :
 Posterior triangle (behind the posterior
border of the sternocleidomastoid muscle)
 Anterior triangle (in front of the anterior
border of the sternocleidomastoid muscle)
 The anterior triangle is subdivided into Zone
I, Zone II, and Zone III. Zone I is below
a horizontal line at the level of the cricoid
cartilage, Zone III is above the angle of the
mandible, and Zone II lies in between.

7. Triangles of neck

8. Triangles of neck (cont)

9. Zones of the neck

10. The anatomical structures potentially
injured
 Blood vessels
 Nerves
 Airway
 Pharynx and oesophagus
 Lymphatics
 Glands

11. Posterior triangle
 Generally these injuries are less likely to
involve the major structures.
 The spinal cord, brachial plexus, and
vertebral arteries may be at risk.
 If the injury is very low, the subclavian
vessels or the lung apex could be
involved.

12. Anterior triangle
Zone I
 Blood vessels : aortic arch, subclavian, and
innominate (brachiocephalic) vessels
 Nerves : brachial plexus, left recurrent
laryngeal nerve, spinal cord, sympathetic
trunks
 Respiratory : trachea, apex of the lung
 Digestive : oesophagus
 Lymphatic : thoracic duct on the left
 Thyroid gland.

14. Anterior triangle (cont)
Zone II
 Blood vessels : carotid vessels, internal
jugular vein
 Nerves : vagus, recurrent laryngeal,
phrenic nerve
 Respiratory : trachea, larynx
 Digestive : oesophagus

15. Anterior triangle (cont)
Zone III
 Blood vessels : carotid vessels, internal
jugular vein
 Nerves : cranial nerves VII-XII
 Respiratory/ digestive : pharynx
 Parotid gland

16. Presentation
Clinical signs of significant injury
 Dysphagia – Tracheal and/or esophageal
injury
 Hoarseness – Tracheal and/or esophageal
injury (especially recurrent laryngeal
nerve)
 Oronasopharyngeal bleeding – Vascular,
tracheal, or esophageal injury
 Neurologic deficit – Vascular and/or spinal
cord injury
 Hypotension – Nonspecific; may be related
to the neck injury or may indicate trauma
elsewhere

17. Presentation (cont)
hard signs of airway injury
 respiratory distress,
 Air bubbling through the neck wound,
 major hemoptysis
soft signs of airway injury
 subcutaneous emphysema
 hoarseness
 minor hemoptysis.

18. Presentation (cont)
hard signs that strongly indicate vascular injury
 severe active bleeding,
 large expanding hematoma,
 Absent or diminished peripheral pulse,
 bruit on auscultation
 Unexplained hypotension
 Ischemia of distal part (cerebral ischemia)
Soft signs of vascular injury
 stable, small to moderate size hematomas,
 minor bleeding,
 mild hypotension responding well to fluid resuscitation
 proximity wounds

19. Presentation (cont)
There are no hard signs diagnostic of
pharyngoesophageal injuries.
Soft signs that require evaluation of the
pharynx and esophagus include
 painful swallowing
 subcutaneous emphysema
 hematemesis.

20. Primary survey
The assessment and management of neck injuries
must follow the ATLS primary survery principles
Airway
 Airway compromise may be directly due to injury
or blood; or secondary, e.g. oedema associated
with a haematoma, or vocal cord paralysis
secondary to injury to the recurrent laryngeal
nerve.
 If the airway is compromised, oral intubation
should be attempted whenever possible but
facilities to perform an emergency surgical airway
procedure must be present.
 If there is an obvious open injury to the airway, it
is better to consider tracheostomy as soon as
possible.
 Routine C-spine immolization is not recommended.

21. Primary survey (cont)
Breathing
 The apex of the lung may be involved when a neck wound is
present.
 Always do a chest X-Ray to check for a haemo- or
pneumothorax.
Circulation
 Vascular injuries may present as neurological complications,
e.g. neurological fallout in the distribution of the middle
cerebral artery may be secondary to a carotid artery injury.
 A high-flow intravenous line should be set up. Intravenous
lines should be avoided in the arm on the side of the neck
wound.
 Active external bleeding can be controlled by external digital
pressure or by inflating the bulb of a Foley’s catheter that has
been carefully inserted as deep as possible into the wound.
This is an emergency measure that provides temporary
control until surgery can be done.

22. Balloon tamponade for bleeding control from the subclavian vessels. It
can also be used for bleeding control from other zones in the neck.

23. Primary survey (cont)
Disability
 Neurological deficit may be secondary to
vascular injury; cranial nerve or spinal
cord damage.
Exposure/ environment
 Look for other injuries – consider injury
patterns associated with the mechanism of
injury, or the trajectory.

24. Secondary Survey
History
 Establish the mechanism of injury, note voice change, ask about
chest pain, dysphagia, haemoptysis, weakness, paresthaesia, or
numbness in the arms.
Examination
Assess for the presence of :
 Local bleeding, pulsation, bruit, absent pulses, expanding
haematoma
 Air in soft tissues, distended neck veins
 Fluid leaking from the wound (saliva, CSF, lymph)
 Cranial nerve deficit, particularly CN VII-XII, Horner’s syndrome
 Loss of sensation and power in the upper limbs
 Loss of sensation and power in the lower limbs
 Pneumo-/ haemothorax, abnormal breathing pattern (e.g.
diaphragmatic breathing)
 Blood pressure difference of more than 10 mmHg in the 2 arms
 Frequent reassessment of the airway is mandatory to check for
impending obstruction due to oedema

25. Investigative management
 The mechanism of injury and clinical
examination should determine the need
and type of specific investigations in the
evaluation of PNI.
 Patients with hard signs of major vascular
or laryngotracheal injuries should undergo
an operation without any delay for
definitive investigations.

26. Investigative management (cont)
 In the stable patient who has no immediate
indication for surgery, the blood vessels,
respiratory, and digestive systems should be
investigated to rule out injury. This may be done
primarily by surgical exploration, or by utilizing
special investigations which may obviate the need
for surgery.
 Zone II injuries are readily exposed and accessed,
and are therefore often surgically explored without
preoperative investigations. The structures in Zone
I or III are more difficult to visualize
intraoperatively and need more preoperative
planning and preparation.

27. Chest and neck radiographs may be helpful in locating foreign bodies.
This patient has retained bullets in zones 1 and 3.

28. Investigative management
(cont)Chest X-ray
 This is essential in all patients with neck injuries.
 Do not sit patient up; if there is an open wound, it may cause a fatal air
embolism or complicate a cervical spine injury.
Cervical spine X-ray
 Look for the presence of fractures, foreign bodies, or air in soft tissues.
CT scan or CT angiography
 In the stable patient, a spiral CT scan (if available) with intravenous
contrast will provide information on soft tissue, bony structures, wound
trajectory, and vascular injuries.
 Specifically look out for intimal injuries of the carotids.
 Oral contrast can be given if required to identify leaks.
Color Flow Doppler (CFD)
 Color flow Doppler has been suggested as a reliable alternative to
angiography in the evaluation of PNI.

29. Chest radiograph in a zone 1 penetrating injury shows a widened upper
mediastinum which is suspicious for a thoracic inlet vascular injury.
This patient needs angiographic evaluation.

30. Investigative management (cont)
Angiography
 Zone I and Zone III : Consider primary angiography if there is any
indication of a vascular injury, such as a blood pressure difference of more
than 10 mmHg in either arm, widened mediastinum on chest X-ray, bruit,
or haematomas.
 Angiography may be done after CT if non-surgical management of vascular
injuries (stenting or embolisation) is anticipated. CT with contrast is usually
done as a first choice investigation, because the broadest spectrum of
information can be obtained.
Endoscopy
 Endoscopy may show oesophageal injury.
 The sensitivity of either rigid or flexible endoscopy depends on the skill and
experience of the endoscopist.
Gastrografin swallow
 The Gastrografin swallow is not sensitive for Zone III injuries, but is
sensitive for lower injuries, in combination with endoscopy if required.
Bronchoscopy/ laryngoscopy
 Laryngoscopy may be used diagnostically and therapeutically: blood clots
may be removed.
 Bronchoscopy may be indicated in selected cases to diagnose airway
injuries, remove foreign material, or lavage the aireays.

32. Management
 Consider early intubaiton or surgical airway.
 If all the investigations are normal, the
patient may be observed over-night and
discharged home if there is no deterioration.
 A haemothorax should be managed
accordingly.
 If the patient is bleeding, or the airway is
compromised, or the investigations are
abnormal, immediate surgical management is
required.
 Small pharyngeal and tracheal injuries can be
treated conservatively.

33. Western Trauma Association management algorithm for penetrating neck trauma.

34. Pitfalls
 Always adhere to ABCDE for the initial management of
the patient.
 Always frequently reassess the airway in order to
recognise airway problems that may develop over
time.
 Do a thorough assessment of platysmal penetration.
The wound should never be probed as bleeding is
sure to be precipitated.
 Penetrating neck injuries may involve the lung or
mediastinal structures. The chest should always be
assessed.
 Vascular injuries may cause neurological
manifestations.

35. Questions !!!