Category: Trauma
Keywords: penetrating neck trauma, zones, hard signs, operative management (PubMed Search)
Posted: 2/5/2023 by Robert Flint, MD
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The classic teaching regarding penetrating neck trauma is violation of the platysma muscle in zones 1 and 3 requires angiography, endoscopy and bronchoscopy. Injury to zone 2 is an automatic operative evaluation. Now, more anatomic and physiologic signs dictate operative management and those not meeting these hard signs get evaluated with Ct angiography.
Neck zones and hard vs soft signs available by clicking link
| Zone | Boundaries | Structures |
|---|---|---|
| I (lower) | Clavicles and sternum to the cricoid cartilage | Vascular: subclavian arteries and veins, jugular veins, carotid arteries, vertebral arteryAerodigestive: lungs, trachea, esophagusNeurologic: spinal cord, vagus nerveOther: thoracic duct, thyroid gland |
| II (middle) | Cricoid cartilage to the angle of the mandible | Vascular: common/internal/external carotid arteries, vertebral arteries, jugular veinsAerodigestive: trachea, larynx, pharynx, esophagusNeurologic: spinal cord, vagus nerve, recurrent laryngeal nerve |
| III (upper) | Angle of the mandible to the base of the skull | Vascular: internal carotid arteries, vertebral arteries, jugular veinsAerodigestive: pharynxNeurologic: spinal cord, CN IX, X, XI, XI, sympathetic chainOther: salivary glands |
Hard SignsVascular injury
Severe uncontrolled hemorrhage
Refractory shock/hypotension
Large, expanding, or pulsatile hematoma
Unilateral extremity pulse deficit
Bruit or thrill
Neurologic deficit consistent with strokeMinor bleeding
Soft Signs Vascular
Small, nonexpanding hematoma
Proximity wound
Hard SignsAerodigestive tract injuryAirway compromise
Bubbling through wound
Extensive subcutaneous emphysema
Stridor
Hoarse voice
Soft Signs
Mild hemoptysis
Mild hematemesis
Dysphonia
Dysphagia
Mild subcutaneous emphysema
Protect That Neck! Management of Blunt and Penetrating Neck Trauma
Matt Piaseczny, MD, MSc Julie La, MD, MESc Tim Chaplin, MD Chris Evans, MD :https://doi.org/10.1016/j.emc.2022.09.005
