Penetrating neck injuries: a guide to evaluation and management

Abstract

Introduction Penetrating neck injury is a relatively uncommon trauma presentation with the potential for significant morbidity and possible mortality. There are no international consensus guidelines on penetrating neck injury management and published reviews tend to focus on traditional zonal approaches. Recent improvements in imaging modalities have altered the way in which penetrating neck injuries are now best approached with a more conservative stance. A literature review was completed to provide clinicians with a current practice guideline for evaluation and management of penetrating neck injuries. Methods A comprehensive MEDLINE (PubMed) literature search was conducted using the search terms 'penetrating neck injury', 'penetrating neck trauma', 'management', 'guidelines' and approach. All articles in English were considered. Articles with only limited relevance to the review were subsequently discarded. All other articles which had clear relevance concerning the epidemiology, clinical features and surgical management of penetrating neck injuries were included. Results After initial resuscitation with Advanced Trauma Life Support principles, penetrating neck injury management depends on whether the patient is stable or unstable on clinical evaluation. Patients whose condition is unstable should undergo immediate operative exploration. Patients whose condition is stable who lack hard signs should undergo multidetector helical computed tomography with angiography for evaluation of the injury, regardless of the zone of injury. Conclusions The 'no zonal approach' to penetrating neck trauma is a selective approach with superior patient outcomes in comparison with traditional management principles. We present an evidence-based, algorithmic and practical guide for clinicians to use when assessing and managing penetrating neck injury.

Keywords: Management; Penetrating neck injury; Review; Trauma.

Figure 1

Classification of anatomical zones of the neck (Monson 1969). Zone 1 extends from clavicles to cricoid, zone II from cricoid to angle of mandible, and zone III from angle of mandible to skull base.

Figure 2

Foley catheter balloon tamponade. A Foley catheter is introduced into the bleeding neck wound following the wound track. The balloon is inflated with 10–15 ml water or until resistance is felt. The catheter is clamped to prevent bleeding through the lumen. The neck wound is sutured around the catheter.

Figure 3

Foley catheter balloon tamponade in a zone 2 neck injury. The catheter is knotted on itself (black arrow) acting as a clamp to prevent flow of blood through the lumen. The wound is suture around it (white arrow).

Figure 4

Algorithm for no-zonal management of penetrating neck injury. Approach patients with a penetrating neck injury like any trauma patient with Advanced Trauma Life Support resuscitation. Patients who are unstable and demonstrating any of the ‘hard signs’ or visceral injury must be immediately taken for surgical exploration. All patients who are stable should have a multidetector helical computed tomography with angiography to evaluate for visceral injury.