Penetrating Neck Trauma

Charles E. Lucas, MD, and Anna M. Ledgerwood, MD

OVERVIEW
The neck may be divided into bilateral anterior and posterior triangles by the sternocleidomastoid (SCM) muscles. Wounds to the
posterior cervical triangles require operative management only for
the control of bleeding and repair of wounds; there are no hidden
structures that lead to late complications when not treated promptly.
Consequently, the challenges regarding care of penetrating neck
wounds relate to injuries in the anterior triangles. These challenges
include 1) emergent airway control, 2) immediate control of active bleeding, 3) urgent operative treatment of major injuries not causing acute
airway compromise or life-threatening bleeding, 4) urgent diagnostic
investigations for patients not requiring emergent or urgent operation,
5) deciding whether to explore or observe stable patients, 6) optimal
exposure for patients requiring operation, and 7) care of specific injuries.

EMERGENT AIRWAY PROBLEMS

Potentially life-threatening airway injuries may be caused by tracheal
or cartilaginous rupture, soft-tissue compression of the airway from
adjacent arterial injury, or active hemorrhage into the tracheobronchial tree due to a vascular-airway fistula. Air escape through the skin
wound, dyspnea, stridor, hoarseness, or significant subcutaneous
emphysema points toward airway disruption. The stable patient with
hemoptysis wishes to sit up and lean forward in order to efficiently
expectorate blood that enters the airway. Forcing the patient to lie
down should be avoided until all preparations have been made for a
rapid sequence intubation (RSI).
Ideally, the intubation is performed in the operating room by
experienced anesthesia personnel. When excessive bleeding into the
oral cavity is not present, an oral intubation should be successful;
when bleeding obscures the passages, a fiberoptic nasotracheal intubation may be accomplished by experienced personnel. Although a
coniotomy (cricothyroidotomy) is usually not needed in this circumstance, the resuscitation team should be mentally prepared to utilize
this approach in patients suspected of having airway rupture.
Significant hemoptysis portends an arterial tracheal fistula; when
the endotracheal tube is inserted, the balloon should be inflated at
or below the site where the fistula is most likely located. Likewise,
when a coniotomy is needed, the tracheostomy tube balloon should
be positioned to occlude the fistula. After airway control, immediate
neck exploration is performed.

EXTERNAL BLEEDING
Major external bleeding or a pulsatile hematoma are indicative of an
artery injury. Direct digital pressure with the gloved finger is the optimal way to provide temporary control of bleeding while the patient
is taken to the operating room. Wraps and compression dressings are
ineffective and potentially dangerous. The digital control of bleeding is
maintained during RSI and the preoperative prep of the operative field.

URGENT OPERATION
Patients without life-threatening signs of airway injury or compromise and without uncontrolled external bleeding require urgent
operation when hard signs indicate major injury. These signs include
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a large hematoma, pulsatile hematoma, continued oozing, cervical

crepitus, hoarseness, dyspnea, and large wounds with severance of
soft tissues that need reapproximation.

URGENT DIAGNOSTIC INVESTIGATION

Patients without the above needs for emergent or urgent operative
intervention need to have diagnostic studies performed to exclude
a subtle injury to important structures. These patients may have soft
signs following a penetrating wound in the mid portion of the neck
such as superficial bleeding from the skin or subcutaneous tissue, a
history of bleeding prior to arrival, hoarseness, a bruit, dysphagia,
blood-streaked sputum, or mild neck swelling.
The first component of this urgent investigation is a thorough
physical examination of the neck that includes an intraoral examination to look for blood in the oral cavity and the hypopharynx. Chest
auscultation and examination for trachea deviation help identify a
pneumothorax from a thoracic outlet injury. Chest radiographs will
confirm or rule out a pneumothorax or hemothorax, and tracheal or
esophageal penetration may be identified by combined endoscopy of
the trachea and esophagus. However, small injuries may be missed
with these procedures. Barium swallow, which is potentially hazardous and fails to identify some injuries, is not recommended. CT
angiogram, formal angiography, or color-flow duplex ultrasound will
help identify arterial injury. All these procedures should be promptly
available in the trauma center to provide care for patients with penetrating neck wounds.

NECK EXPLORATION VERSUS

OBSERVATION
The decision to explore a penetrating neck wound in a stable patient
without the so-called hard signs depends upon the diagnostic findings and the zone in which the injury occurred (Figure 1). The
anterior cervical triangles can be divided into three zones. Zone 1
is sometimes referred to as the thoracic outlet and extends from the
clavicle to the cricoid cartilage. A decision to explore zone 1 injuries
would be made on the basis of confirmed injury to the named vessels,
trachea, or esophagus. Zone 2 of the anterior triangles extends from
the cricoid to the angle of the mandible. Formerly, all patients who
had penetration of the platysma muscle in zone 2 underwent mandatory exploration. Most surgeons would now explore zone 2 injuries
only for patients who have evidence of organ injury, hematoma, continued bleeding, or high suspicion for tracheal or esophageal injury.
Zone 3 of the anterior triangles extends from the mandible to the base
of the skull. The decision to explore zone 3 injuries would be based
upon angiographic evidence of arterial injury.

OPERATIVE EXPOSURE
Most penetrating cervical wounds are best explored through an ipsilateral incision along the anterior border of the SCM muscle (see
Figure 1). The incision is extended through the platysma into the
deeper planes; the trachea and thyroid gland are retracted anteriorly, and the neurovascular bundle and esophagus are displaced posteriorly. This exposes the tracheoesophageal groove and allows the
operator to identify when further dissection is needed anteriorly or
posteriorly. Superficial crossing veins are divided and ligated along
with the omohyoid muscle, thus facilitating deeper dissection.
When a zone 3 injury requires repair of the internal carotid artery
at the base of the skull, the mandible can be detached posterior to the
angle and subluxated anteriorly to facilitate a direct primary repair.
When the injury involves zone 1 structures in the thoracic outlet,

T RAUMA AND EME R GE NCY CA R E

Zone 3
Zone 2
Zone 1

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be avoided, unless the patient has no saphenous vein. We prefer to

instill a local heparin solution proximally and distally without using
total body heparinization. A temporary arterial shunt should be used
when the arterial repair cannot be performed promptly (within 30
minutes) because of higher treatment priorities elsewhere.
For zone 2 injuries, the branches of the external carotid artery can
be safely ligated. When there is disruption at the carotid bifurcation,
the intact external carotid artery can be anastomosed to the internal carotid artery distal to the area of irreparable damage. The distal
stump of the external carotid artery is ligated.
Primary carotid arterial repair in patients with a neurologic neural deficit is controversial. This concern, in part, reflects the fear that
a primary repair will convert an ischemic stroke into a hemorrhagic
stroke. The authors recommend repair in this setting, because patients
who subsequently succumb have diffuse cerebral edema without
hemorrhage at the time of the postmortem examination. Control of
intracerebral pressure in these patients may lead to survival.

Esophageal Injuries
FIGURE 1 Zones of the neck and optimal exposures. An incision

along the anterior border of the sternocleidomastoid muscle provides

access to zone 1 and zone 2 injuries. Extension of this incision
inferiorly as a median sternotomy exposes anterior mediastinal injury.
A lateral extension along the medial half of the clavicle and then over
the cephalic vein gives access to the subclavian vessels.

the incision can be extended as a median sternotomy, thereby giving excellent exposure of the trachea, innominate artery, left common
carotid artery, subclavian artery, subclavian veins, innominate vein,
and superior vena cava. When the injury involves the subclavian vessels as they pass laterally, the incision can be tied off over the medial
half of the clavicle and then over the basilic vein, where it passes posterior to the mid-clavicle (see Figure 1). Resection of the medial head
of the clavicle facilitates exposure, control, and repair of the subclavian arteries and subclavian veins. Rarely, a bilateral incision along
the anterior border of the SCM muscles is required for bilateral injuries. We prefer not to combine bilateral incisions by joining them just
superior to the manubrium.

Exposure of the esophagus through the anterior SCM approach permits the esophagus to be freed up from the trachea anteriorly and
the prevertebral fascia posteriorly, where it can be surrounded with
a Penrose drain. The presence of a nasogastric (NG) tube facilitates
identification and safe digital mobilization of the esophagus. Once
mobilized, most unilateral stab wounds can be repaired in two layers,
being certain to incorporate the full-thickness mucosal and muscular
wall in the inverted inner layer with an absorbable suture. The second
layer of the muscular esophagus can be performed with interrupted
4-0 permanent sutures. With bilateral injury, the esophagus can be
rotated to facilitate bilateral simple repair. Alternatively, the injury
on the ipsilateral side of the esophagus can be slightly extended to
permit the contralateral wound to be closed from the intraluminal
approach. The ipsilateral wound can then be closed as described
above. It is essential to identify all injuries to prevent an esophageal
cutaneous fistula from a missed injury.
Following closure, a paraesophageal drain should be left in place.
If any drainage exudes, it should be monitored for amylase. The likelihood of an esophageal cutaneous fistula is low for patients who have
early operative intervention. Once a fistula is confirmed, NG tube
feedings are instituted, while the fistula closes within the ensuing
three weeks. The NG tube is left in place to allow immediate feeding
postoperatively.

REPAIR OF SPECIFIC INJURIES

Venous Injuries

Pharyngeal Injuries

Venous injuries are the most common cause of nonlife-threatening

hemorrhage from penetrating neck wounds. Small veins, including
the external jugular vein, are best ligated. The internal jugular vein
often can be repaired primarily using a running, nonabsorbable fine
suture. When there are large through-and-through wounds to the
internal jugular vein, the vein should be ligated, which is well tolerated by trauma patients.

Perforations of the pharynx and hypopharynx are often suspected

when blood is seen on the deep oral examination, and it may be confirmed at operation by following the penetrating wound tract to the
perforation. Primary closure with full-thickness inverted bites of tissue using absorbable suture provides both hemostasis and a secure
closure.

Arterial Injuries
After proximal control is obtained, dissection should begin just
above the clavicle and proceed distally. Digital pressure of the area
of injury is maintained while distal control is obtained. Once exposure is obtained, most arterial injuries can be treated by a primary
lateral repair using a running 5-0 nonabsorbable suture. When there
is more extensive arterial injury from a gunshot wound, the segment
is resected. When the gap is 1 cm long or less, an end-to-end anastomosis can be accomplished. Resection of longer segments requires a
reversed saphenous vein graft interposition. Prosthetic grafts should

Tracheal and Cartilaginous Injuries

Through the anterior SCM approach, the trachea is freed up posteriorly by blunt dissection in the tracheoesophageal groove. Perforations
of the posterior wall can be repaired with running or interrupted 3-0
absorbable sutures with the knots tied on the outside. Identification
of a posterior wound is essential to be certain there is no adjacent
esophageal injury. Closure of perforations of the anterior wall often
require that sutures be placed in the inner space above the superior
tracheal ring and below the inferior tracheal ring at the site of injury;
the knots are tied on the outside. Cartilaginous injuries, likewise, can
be repaired with sutures heavy enough to go through the cartilage

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Blunt Cardiac Injury

and to provide apposition. Some cartilaginous injuries are best left

alone. Significant tracheal ring injuries often require a formal tracheostomy to ensure airway control and circumvent airway resistance
from the glottis. High tracheostomy insertion at the second tracheal
ring is preferred, even when the actual injury is located more distally.

the surgeon identifies a stab wound with complete severance of the

recurrent laryngeal nerve, a primary approximation is indicated
using fine sutures. The results of such repairs are unknown.
Injuries to the thoracic duct may be recognized by the presence
of lymph within the operative field. The duct should be freed up, isolated, and divided with each end appropriately ligated.

Thyroid Injuries

Suggested Readings

Most wounds that cause tracheal injury will also cause injury to
the thyroid. When the injured thyroid gland is not directly over the
tracheal injury, it may be made hemostatic with simple sutures or
electrocoagulation. When the thyroid injury occurs in the absence
of tracheal injury, simple hemostasis by the above techniques is
required. When the injury goes through the thyroid gland into the
trachea, that portion of the thyroid is best resected. Alternatively, the
thyroid may be divided at the isthmus and rotated off the trachea to
facilitate a primary tracheal repair.

Azuaje RE, Jacobson LE, Glover J, et al: Reliability of physical examination

as a predictor of vascular injury after penetrating neck trauma, Am Surg
69:804807, 2003.
Demetriades D, Theodorou D, Cornwell E, et al: Evaluation of penetrating
injuries of the neck: a prospective study of 223 patients, World J Surgery
21:4148, 1997.
Ledgerwood AM, Mullins RJ, Lucas CE: Primary repair vs ligation for carotid
artery injuries, Arch Surg 115:488493, 1980.
Meyer JP, Barrett JA, Schuler JJ, et al: Mandatory vs selective exploration for
penetrating neck wounds: a prospective assessment, Arch Surg 122:592
597, 1987.

Miscellaneous Injuries
Injuries to the recurrent laryngeal nerve from a penetrating neck
wound are rare. If the injury is the result of a gunshot wound, the
nerve is unlikely to be completely severed and is best left alone. If

Blunt Cardiac Injury

Louis R. Pizano, MD, MBA, and Gerd D. Pust, MD

OVERVIEW
Blunt cardiac injury (BCI) is the general term used for injury that occurs
from blunt trauma to the heart. The wide range of pathophysiologic
changes that result from this type of trauma may be asymptomatic, or
they may lead to death from ventricular wall rupture. Older terminology includes blunt cardiac trauma, cardiac concussion, and cardiac contusion. Cardiac injury is subclassified by pathologic mechanisms into
BCI with 1) complex arrhythmia, 2) minor electrocardiogram (ECG) or
enzyme abnormality, 3) cardiac failure, 4) coronary artery thrombosis,
and 5) septal or 6) free wall rupture. Treatment of these different subclasses of BCI varies from ECG monitoring to complex surgical repair.

INCIDENCE
The true incidence of BCI in patients with chest and abdominal
trauma is unknown. Because it includes a wide spectrum of injury,
from minor myocardial contusion with or without cardiac arrhythmias to severe structural damage, it is difficult to measure an accurate
incidence. Because of the varied presentation of signs and symptoms,
the appropriateness of the diagnostic workup, including the use of
ECG and other imaging studies, such as echocardiography, will influence the incidence in clinical studies. This is reflected in the wide range
in the reported incidence in different case seriesfrom 8% to 71%.
The incidence of BCI in patients with chest and abdominal
trauma is significantly lower in clinical studies as compared with
autopsy series, as many patients with BCI die in the field from either
cardiac or other associated traumatic injuries. Schultz and colleagues
(2004) found that the most common BCI identified in clinical studies

is myocardial contusion (60% to 100%), followed by right ventricular

injury (17% to 32%) and right atrial injury (8% to 65%) because of the
anatomic anterior positioning in the chest.
The left heart is less commonly involved, with left ventricular
injury (8% to 15%) and left atrial injury (0% to 31%) somewhat more
rare. Septal, valve, and coronary artery injuries appear rarely in clinical studies and are documented only as case reports. These injuries
are often lethal and are found primarily at autopsy with studies showing atrial septal defects (7%), ventricular septal defects (4%), valve
injuries (5%), and coronary artery injuries (3%).
The largest autopsy series published by Parmley and colleagues
reviewed 207,548 cases from the Armed Forces Institute of Pathology.
The study showed a 0.1% incidence and identified 546 cases of blunt
traumatic injuries. The most common chamber rupture was the right
ventricle (66 cases), followed by the left ventricle (59 cases), right atria
(41 cases), and left atria (26 cases). Of these, 106 cases had combined
chamber ruptures, and 80 had an associated aortic injury. Turk and
Tsokos (2004), however, reported that blunt atrial injuries are more
common than ventricular injuries, with the most frequently injured
cardiac chambers being the right atrium, followed by the right ventricle.

MECHANISM OF INJURY AND

PATHOPHYSIOLOGY
The heart is well protected by the sternum and rib cage; therefore it
requires significant kinetic energy to the chest to cause a BCI. The
most common causes are motor vehicle collisions and pedestrians
struck by vehicles. Events that lead to acute deceleration and torsion, such as falls, as well as thoracic crush injuries are also common causes of BCI. Other blunt mechanisms include blast injuries,
assaults, and sports-related trauma, which can cause direct precordial impact. Severe abdominal compression can lead to rupture of the
right atrium and ventricle secondary to increased hydrostatic pressure. Hydraulic effects from a sudden increase in blood return via the
inferior vena cava leads to rupture of these chambers from rapidly
increasing pressure.