Penetrating neck injury

North of Scotland major trauma guidelines
NHS Grampian

Anatomical zones of the neck

Diagram showing zones 1, 2 and 3 of the neck.
Image credit: NECK TRAUMA Rosen Emergency Medicine 10th Edition (Chapter 36)
  • Zone 1: Clavicle and sternal notch to cricoid cartilage
  • Zone II: Cricoid cartilage to the angle of the mandible
  • Zone III: Angle of mandible to base of skull.

Management principles

Consider a definitive airway early in penetrating neck injuries

  • If the platysma is not breached, a significant injury is effectively excluded.
  • If this distinction cannot be made, then further investigation is required.
  • Ensure early airway assessment and consider a definitive airway early where appropriate.

Access for hard and soft signs

Hard signs Soft signs
  • Active haemorrhage
  • Pulsatile / expanding haematoma
  • Bruit/thrill
  • Haemodynamic instability
  • Unilateral upper limb pulse deficit
  • Massive haemoptysis / haematemesis
  • Air bubbling in the wound
  • Airway compromise
  • Cerebral Ischemia
  • Major Haemorrhage
    • Apply direct pressure
    • Consider haemostatic dressings
    • Foley catheter
  • Non pulsatile / non-expanding haematoma
  • Venous oozing
  • Dysphagia
  • Dysphonia
  • Subcutaneous emphysema

Imaging vs. theatre

  • Unstable patients with hard signs require emergency surgery.
  • Perform immediate CTA Neck in patients with hard signs not requiring emergency surgery.
  • Perform immediate CTA Neck in patients with soft signs.

Other injuries to consider

If there is concern for aerodigestive injury despite normal / equivocal CTA:

  • Consider Barium Swallow in conjunction with laryngoscopy / esophagoscopy.
  • Consider ENT and cardiothoracic involvement as required. Some Zone 1 injuries will require a thoracotomy for proximal control.