This document discusses penetrating neck trauma. It begins by outlining the anatomy of the neck and dividing it into three zones. It then discusses the mechanisms of injury, signs indicating injury to structures like blood vessels, and considerations for resuscitation and investigation. Hard signs that require emergency surgery include uncontrolled bleeding or shock. Soft signs may allow for further investigation with imaging or endoscopy before deciding on exploration. Surgical management depends on the injured zone, and may involve sternotomy, collar incisions, or mandible resection.

1. Penetrating neck
trauma
Tim Martin

2. Introduction
❖ Anatomy and Zones
❖ Hard and soft signs
❖ Resuscitation
❖ Investigation
❖ Management

3. Introduction
❖ Penetrating neck injuries vs
blunt trauma
❖ Injury through the platysma
muscle
❖ Mechanisms of injury
http://www.innerbody.com/image_musfov/musc18-new.html
https://academic.amc.edu/martino/grossanatomy/site/medical/lab%20manual/gastrointestinal/Dissections/Anterior%20Triangle/Anterior%20Triangle1.htm

4. Ballistic injuries
❖ Kinetic energy = mass x
velocity squared / 2
❖ Greater tissue disruption from
high mass or velocity
projectiles
❖ Yaw
❖ Deformation/Fragmentation

5. Historically
❖ Carotid ligation vs observation
❖ High mortality associated with injury
❖ World War II - exploratory surgery in all patients
❖ High negative exploratory rates - zone based approach
❖ All zone 2 injuries explored, zone 1 + 3 explored based
of symptoms due to complications of the surgeries

6. Anatomical approach
❖ Zone 1: Clavicle to the cricoid
cartilage
❖ Zone 2: Cricoid cartilage to
angle of mandible
❖ Zone 3: Above angle of the
mandible
❖ Site of external wound vs
where projectile passes

7. Structures at risk
❖ Vascular - carotid arteries, vertebral arteries, jugular veins
❖ Aerodigestive - larynx/pharynx/trachea, oesophagus
❖ Neurological - Spinal cord
❖ Zone 1 can extend into thorax and include thyroid gland
❖ Zone 2 includes vagus and recurrent laryngeal
❖ Zone 3 includes cranial nerves IX, X, XI and XII

8. Hard and Soft Signs
HARD SIGNS SOFT SIGNS
Uncontrollable haemorrhage/Shock Haemorrhage responding to fluid resuscitation
Expanding or pulsatile haematoma Non pulsatile or expanding haematoma
Absent radial pulse Subcutaneous emphysema
Thrills/Bruits Dysphonia/Dysphagia
Neurological deficit indicating ischaemia
Haemoptysis/Haematemesis
Respiratory distress/Stridor
Visible air bubbles from wound

9. Resuscitation considerations
❖ Catastrophic bleeding
❖ C Spine - consider the mechanism, neurological findings
❖ Immobilised C Spine may make further assessment and
observation of penetrating neck injuries difficult
❖ Ramasamy et al 2009 - Review of British soldiers from Iraq war
- 56 surviving to surgery, 1 patient unstable C Spine
❖ C Spine fracture from gunshot wound vs stab wound was
1.35% and 0.12% retrospectively: study quoted UpTo date
Rhee et al

10. Resuscitation considerations
❖ Airway
❖ RSI vs surgical airway
❖ Visible trachae - secure to
prevent retraction into thorax
❖ Fiberoptic guided intubation
❖ Specific risks - false lumen out
of trachea, exacerbation of
injury
http://clinicalgate.com/penetrating-neck-trauma/

11. Resuscitation considerations
❖ Breathing - pneumothorax; in
cardiac arrest with penetrating
neck trauma - thoracotomy
❖ Circulation - fluid/blood
resuscitation, pressure
❖ Disability - neurological deficit
❖ Exposure - associated injuries
http://resus.me/simple-emergency-haemorrhage-control/

12. Investigation
❖ Bloods and crossmatch
❖ CXR
❖ Ultrasound
❖ CT with angiography/thin slice helical
❖ Direct visualisation - laryngoscopy/oesophagoscopy

13. Management
❖ Early surgical consultation
❖ If hard signs for theatre for exploration
❖ Soft signs - investigate - theatre/observe
❖ Possible surgical approaches:
❖ Zone 1 - median sternotomy
❖ Zone 2 - transverse cervical collar incision
❖ Zone 3 - dislocation/resection of mandible
❖ Endovascular approach

14. References
❖ Tintinalli’s Emergency Medicine 8th Edition
❖ UpTo Date Penetrating Neck Injuries: Initial evaluation
and management Feb 2017; Kim Newton
❖ Ramasamy et al. Learning lessons from conflict: Pre-
hospital cervical spine immobilisation following ballistic
neck trauma. Injury. 2009