Penetrating Neck Trauma

Annotation for Point C

Patients without indications for mandatory neck exploration who remain hemodynamically stable can be managed expectantly with observation/serial examinations or undergo further radiographic evaluation, depending on the level of suspicion for injury, the symptoms demonstrated by the patient, and the anatomic zone of injury. Patients without symptoms such as dysphagia, voice change, hemoptysis, hematemesis, x-ray finding abnormality, or a bruit/thrill can be safely managed expectantly with serial examinations and observation.5,17 A thorough physical examination following penetrating neck injury has been demonstrated to be highly sensitive (>95%) for detecting arterial vascular injury but a lower sensitivity for aerodigestive tract injuries.15,37,38 Patients who are asymptomatic with Zone I injuries require a high index of suspicion because physical examination findings can be anatomically obscured.5,39  In the most recent prospective, multicenter study, evaluating 453 patients over 31 monthwas, all 189 patients without physical examination findings of vascular or aerodigestive tract injury were observed and discharged without a missed injury (mean, 2.6-day follow-up).15 However, owing to the greater morbidity and mortality associated with delayed management of esophageal injury and potential lower sensitivity of physical examination, the most current published clinical practice guidelines recommend that physical examination alone is inadequate to rule out injuries to the aerodigestive tract.4 Similarly, physical examination was shown to have a lower sensitivity of detecting venous injuries as compared with computed tomographic angiography (CTA); however, most venous injuries do not require intervention.37 Stable patients with transcervical gunshot wounds may warrant further radiographic evaluation owing to their greater injury potential and likelihood to involve more than one anatomic zone of injury.40