Penetrating Neck Trauma
Annotation for Point E
In hemodynamically stable patients with CTA evidence of Zone I injury, further intervention is typically required. Successful endovascular approaches for arterial injuries using covered stents for Zone I injuries have been documented, although primarily as case reports and small series.26,41 When endovascular techniques are not indicated, are unavailable, or are unsuccessful, standard open surgical techniques using proximal and distal vascular control is required for arterial/venous injuries. Hemodynamically stable patients with documented Zone I aerodigestive injury by CTA should undergo prompt operative intervention in most cases because this is associated with better outcome.42 The treatment strategy for esophageal injury is typically determined by the clinical status of the patient, associated injuries, and extent and location of esophageal injury. Access can be from the neck or the chest, or at times, both are required. Goals for early operative management include debridement of the esophagus, primary closure with buttressing if possible, and adequate drainage.42-44 Tracheal injury can usually be primarily repaired using absorbable suture after appropriate debridement. Interposition of a well-vascularized tissue between a combination of tracheal and esophageal injuries is essential to reduce the risk of fistula development.45 Patients without documented aerodigestive injury by CTA imaging but with concerning trajectory should undergo further evaluation with esophagoscopy or esophagography and bronchoscopy, possibly intraoperatively if other injuries are being treated operatively.