Patients with penetrating or blunt trauma to the neck present with overt symptoms and/or signs,

moderate or modest symptoms and/or signs, or they are asymptomatic without signs of
aerodigestive or vascular injury. The presentation of a patient with overt symptoms or signs will
vary depending on the zone of the neck involved. In Zone I a vascular injury from a penetrating
wound may cause external hemorrhage from the thoracic outlet or intrapleural exsanguination. A
penetrating wound in Zone II or blunt disruption of the cricotracheal junction secondary to a
“clothesline” injury may lead to loss of the airway and early asphyxiation. Loss of the airway can
occur secondary to the presence of a large hematoma from an injury to the carotid artery, as well.
Active hemorrhage from either the carotid artery or internal jugular vein in Zone II can be external
and lead to exsanguination or internal bleeding into an associated injury to the trachea, leading to
aspiration and asphyxiation. While injures in Zone III are uncommon, exsanguination can occur
from an injury to the internal carotid artery at the base of the skull.

Patients with modest or moderate symptoms or signs may present with complaints of hoarseness,
dysphagia, or odynophagia and palpable crepitus suggestive of injury to the larynx, trachea, or
esophagus. The other presentations in this group are proximity of penetrating wound or blunt
contusion to the carotid sheath and/or a stable hematoma suggestive of injury to the carotid
artery or internal jugular vein.

An asymptomatic patient will have penetration of the platysma muscle by a gunshot or knife
wound or bruising or contusion after blunt trauma, but have no symptoms or signs of injury to the
aerodigestive tracts, cervical vessels, the spine, or the spinal cord.

Management of the patient depends on presentation. Overtly symptomatic patients have “A, B, or
C” problems on the primary survey as taught in the Advanced Trauma Life Support course, and
immediate resuscitation is performed in the emergency center or operating room (see below).
Patients with modest or moderate symptoms or signs undergo a diagnostic evaluation referable to
the suspected system injured or one that encompasses the aerodigestive and arterial systems.

Asymptomatic patients are discharged, admitted for observation, or, in some centers, undergo a
limited radiologic evaluation (i.e., cervical computed tomography [CT]).

MANAGEMENT OF PATIENTS WITH OVERT SYMPTOMS OR SIGNS

In patients with exsanguinating external hemorrhage from the thoracic outlet or the lower
anterior neck, usually from a penetrating wound, blind finger compression of the bleeding vessel
through the skin defect is appropriate in the emergency center ( Fig. 22-2 ). If this is unsuccessful,
rapid enlargement of the skin defect with or without local anesthesia is performed.

Once again, an attempt is made to compress the bleeding vessel with two or three fingers inserted
through the enlarged skin defect. An unsuccessful attempt is followed by tight packing of the area
using 3- or 4-in gauze and rapid transport to the operating room. The operative incision will
depend on the track of the wound, whether or not manual compression or packing has controlled
the bleeding, and the patient’s hemodynamic status. For example, a wound thought to involve the
proximal common carotid artery at the base of the neck rather than more proximally in the
mediastinum is exposed with the standard anterior oblique invasion on the side of injury. An
unstable patient with continuing hemorrhage from the outlet or presumed intrapleural
exsanguination should undergo a high anterolateral thoracotomy (fourth intercostal space above
the male nipple) on the side of the injury to allow for direct proximal clamping or pack
compression of the injured vessel in the thoracic outlet. If the wound is on the right side of the
thoracic outlet and the patient is profoundly hypotensive, the sternum is divided transversely and
a standard (below the nipple) left anterolateral thoracotomy is performed, as well. This will allow
for cross-clamping of the descending thoracic aorta to increase perfusion to the coronary and
carotid arteries as resuscitation and vascular repair or ligation are accomplished.

In Zone II a penetrating wound may cause impending asphyxiation from a major injury to the
trachea (suggested by a continuing air leak from the entrance site). The skin defect is rapidly
enlarged with or without local anesthesia, and an endotracheal tube is inserted through the
enlarged track following the air bubbles into the distal end of the trachea once it is visualized ( Fig.
22-3 ). The aforementioned “clothesline” injury from blunt trauma may cause cricotracheal
separation. Even with impending asphyxiation there should only be one attempt at standard rapid
sequence endotracheal intubation. 9 , 10 If this is unsuccessful, a rapid standard tracheostomy is
performed between the second and third tracheal rings below the area of injury. Should there be
bruising and palpable crepitus over the thyroid cartilage suggestive of an injury to the larynx itself,
once again there should only be one attempt at standard endotracheal intubation. Failure to
complete this is followed by a rapid standard tracheostomy much as with cricotracheal separation.

Loss of the airway in Zone II may occur secondary to tracheal deviation or compression from a
hematoma resulting from injury to the carotid artery or internal jugular vein, also ( Fig. 22-4 ).
With impending asphyxiation, the patient is rapidly moved to the operating room for an attempt
at endotracheal intubation over a fiber-optic bronchoscope. If this fails or if the patient is unable
to move air when first seen, a cricothyroidotomy is performed rapidly as its high limited central
incision (as compared to a standard tracheostomy) avoids the lateral hematoma from the vascular
injury.

With external hemorrhage from a penetrating wound in Zone II, direct compression with a finger
or fist on the entrance site is performed in the emergency center and en route to the operating
room. The decision on where to make the incision can be made in the operating room after
endotracheal intubation has been performed. On rare occasions, there may be internal
hemorrhage into the airway when there are adjacent injuries to the carotid artery and trachea.
While compression is placed on the carotid artery at the entrance site or at the base of the neck, a
cricothyroidotomy is performed. As aspiration is likely to have occurred, fiber-optic bronchoscopy
is performed once the injury to the carotid artery has been repaired. There are two options when
exsanguinating hemorrhage occurs from a penetrating wound to the internal carotid artery at the
base of the skull in Zone III. 11 Finger compression is often only partially successful in this location
as the internal carotid artery is deep to the mandible. The quickest option is to maintain manual
compression as the patient is moved rapidly to the operating room. Once the patient is intubated
and the neck is draped, a #3 or #4 Fogarty balloon catheter is inserted into the wound, advanced 2
cm, and the balloon is inflated 12 , 13 ( Fig. 22-5 ). If hemorrhage continues, the balloon is deflated
and advanced 1 cm at a time and inflated till balloon tamponade controls the hemorrhage. The
catheter is then sutured to the skin and the balloon left inflated for 24 hours.

When external passage of the balloon catheter is partially successful or unsuccessful, a Foley
balloon catheter is passed as it has a larger balloon. If this is unsuccessful, as well, the catheter is
removed and manual compression is applied once again. A standard oblique cervical incision on
the anterior border of the sternocleidomastoid muscle is made, the internal carotid artery is
exposed, and a small arteriotomy is made in the middle of a 6-0 polypropylene purse-string suture.
Once again, a #3 or #4 Fogarty balloon catheter is passed through the arteriotomy and inflated
sequentially until balloon tamponade is successful. On rare occasions, it may be necessary to pass
balloon catheters through the entrance site and through the internal carotid artery
simultaneously. A baseline EEG is performed at this time. This is followed by a contralateral carotid
arteriogram to evaluate the extent of crossover flow to the side of the brain that has been
rendered possibly ischemic by balloon occlusion of the internal carotid artery. Even in the patient
with adequate crossover flow, every attempt should be made to keep the patient normotensive
with a 100% oxygen saturation level. An intracranial pressure monitor is appropriate, as well, so
that treatment can be initiated when ischemic edema occurs. When the baseline EEG is abnormal
and the contralateral carotid arteriogram documents inadequate crossover flow, cerebral ischemia
is occurring. This is expected in patients who have had a period of significant hypotension
secondary to exsanguination prior to inflation of the balloon. In the past, it was recommended
that a patient with ipsilateral cerebral ischemia undergo a saphenous vein bypass from the cervical
internal carotid artery to the petrous portion through a small temporal craniotomy. 14 Currently,
deflation of the balloon(s) and rapid insertion of an endovascular stent into the high internal
carotid artery would be the procedure of choice. 15

EVALUATION OF PATIENTS WITH MODEST OR MODERATE SYMPTOMS OR SIGNS OR

ASYMPTOMATIC PATIENTS ( FIG. 22-6)

■ Zone I

Hemodynamically stable patients with penetrating wounds in proximity to the thoracic outlet
should undergo surgeon performed ultrasound and a chest x-ray. The ultrasound will rule out an
associated cardiac injury and document the presence of a hemothorax or pneumothorax. The
chest x-ray will aid in tracking the course of the missile and in documenting the presence of a
hematoma in the superior mediastinum, base of the neck, or supraclavicular area. There have
been several retrospective studies that have documented that a normal physical examination and
chest x-ray virtually exclude a vascular injury at the thoracic outlet. 17 , 18 Even so, certain trauma
centers will use a screening CT as an added study to determine the track of a penetrating wound in
this area. 19 When the track of a missile or knife wound is in proximity to vessels at the thoracic
outlet and there is an adjacent hematoma on the chest x-ray, digital subtraction arteriography
(DSA) of the carotid, vertebral, and subclavian arteries or a CT arteriogram (CTA) is performed. This
will document the presence and location of a vascular injury and allow for the choice of an
appropriate operative incision.

There are symptoms (hoarseness, dysphagia, odynophagia),signs (palpable crepitus, continuing air
leak through the wound), or findings on a cervical or chest x-ray (cervical or mediastinal air) that
suggest a possible injury to the trachea or esophagus. The diagnostic workup is described in
Section “Zone II.”

Zone II

The approach to possible injuries in this zone has varied considerably over the past 55 years.
Based on the report by Fogelman and Stewart 20 at Parkland Memorial Hospital in 1956,
mandatory exploration for wounds penetrating the platysma muscle was recommended. This
recommendation was based on a mortality rate of 6% in patients undergoing early operation
versus 35% in those undergoing delayed operation.

It quickly became obvious, however, that cervical explorations in all patients (overtly symptomatic,
modestly or moderately symptomatic, asymptomatic) with penetration of the platysma muscle in
Zone II resulted in a “negative” exploration rate of approximately 50%. 21 A more selective
approach to operation based on symptoms and signs as described above was then adopted by
many centers. One review article in 1991 comparing the two approaches noted that mandatory
cervical exploration for platysma penetration had a mortality rate of 5.8% versus 3.7% for a
selective approach. 22 Of interest, a negative or nontherapeutic cervical operation occurred in
46.2% of patients treated with mandatory exploration. When patients with modest or moderate
symptoms or signs or those who are asymptomatic are managed with a selective approach, only
55–65% eventually come to operation. Numerous large studies subsequently verified the safety of
a selective approach in the 1980s and 1990s. 23 – 33