Penetrating Neck Trauma

Annotation for Point B

Operative exposure for penetrating neck injuries with ‘‘hard signs’’ or hemodynamic instability are determined by the anatomic zone of injury.⁸ Most penetrating neck injuries can be approached via an anterior sternocleidomastoid incision. Zone I neck injuries may require a median sternotomy with extension to an anterior sternocleidomastoid incision or supraclavicular incision with or without clavicular head resection. For Zone II transcervical injuries, a transverse cervical collar incision may provide access to both sides of the neck, with the potential to extend along the anterior sternocleidomastoid muscle. Zone III represents a difficult anatomic zone of injury for distal vascular control. At times, subluxation, dislocation, or resection of the mandible may be necessary to gain operative vascular control. Endovascular techniques have become a useful adjunct and an addition to the armamentarium available for the management of the acutely injured patient.^23-26 Depending on institutional availability, Zone I or III vascular injuries may benefit from endovascular management to provide either vascular control or definitive care, if hemodynamic stability can be obtained, if bleeding can be stabilized, or if these techniques can be performed in an expeditious fashion in the operating room.^26-29 Vertebral artery injuries can be challenging, and for these difficult-to-access injuries, external bone wax compression can provide temporary control of bleeding, potentially allowing time for definitive surgical control of bleeding or allowing time for endovascular techniques to obtain definitive control of bleeding, if required. Alternatively, proximal ligation at the vessels origin or insertion of a Fogarty catheter into the proximal vertebral artery for occlusive control may be performed.^23,30-32 When a common or internal carotid arterial injury is identified by neck exploration, current consensus agrees that primary repair of the artery is preferred to ligation, irrespective of any abnormality in focal preoperative neurologic examination findings.^33,34 A majority of jugular venous injuries are probably unrecognized without exploration owing to the low-pressure venous system.³⁵ The majority of jugular venous injuries can be managed safely nonoperatively.³⁶ In those that result in significant hemorrhage or are found at exploration, ligation can be performed with little risk of ramifications.³⁵