Penetrating neck injuries: Initial evaluation and management

INTRODUCTION — Penetrating neck injuries (PNIs) refer to neck injuries resulting from gunshot wounds, stab wounds, or penetrating debris (eg, glass or shrapnel) that penetrate the platysma. PNI can cause life-threatening injuries to the aerodigestive and neurovascular systems.

The initial evaluation and management of PNIs is reviewed here. General evaluation of the trauma patient and the management of other injuries are discussed separately.

●General adult trauma: (see "Initial management of trauma in adults" and "Approach to shock in the adult trauma patient")

●General pediatric trauma: (see "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury" and "Trauma management: Overview of unique pediatric considerations")

●Penetrating thoracic trauma: (see "Initial evaluation and management of penetrating thoracic trauma in adults" and "Approach to the initially stable child with blunt or penetrating injury")

EPIDEMIOLOGY — Penetrating neck injuries (PNIs) comprise 5 to 10 percent of traumatic injuries in adults and are caused primarily by bullets, knives, and other impaling objects (eg, shrapnel, glass). Wounds caused by low-velocity guns or impaling objects tend to cause fewer aerodigestive and vascular injuries [1]. High velocity injuries carry a greater likelihood of serious injury and death [2]. Mortality from PNI during the past decade is reported to be approximately 5 percent in both civilian and war populations.

PNI has been categorized by anatomic zones (figure 1), which are described below. Mortality rates for PNIs appear to be highest with zone I injuries (below the cricoid cartilage) due in part to the proximity of mediastinal structures, the severity of the vascular injuries sustained, and surgical challenges. Exsanguination is the most common cause of immediate death, and the carotid artery is the structure most often involved [3,4]. The incidence of carotid artery injury from a PNI ranges from 6 to 17 percent [5,6]. Concomitant injury beyond the neck is common [7]. (See 'Anatomy' below.)

A review of studies published from 1963 through 1990, which included over 2495 patients with PNI, reported that zone II injuries (between cricoid cartilage and angle of the mandible) are most common, followed by zone I and then zone III (above the angle of the mandible to the base of the skull) [4]. According to this review, the aerodigestive tract was injured most frequently. Ten percent of such patients had laryngeal or tracheal injury, and 9.6 percent had pharyngeal or esophageal wounds. Vascular injuries were also common: 9 percent of patients sustained internal jugular vein injury, and 6.7 percent sustained carotid artery injury. Spinal cord injury occurred in 3 percent. Less common injuries included the subclavian artery (2.2 percent), vertebral artery (1.3 percent), brachial plexus (1.9 percent), cranial nerves IX and X (0.9 percent), and the thoracic duct (<0.1 percent).

Mortality from penetrating laryngotracheal trauma is reported to be 20 percent [8]. Mortality from pharyngoesophageal injuries is as high as 22 percent [9]. Unstable cervical spinal column injuries are rare [10].

ANATOMY — Neck anatomy is complex with aerodigestive and neurovascular structures confined to a small area. The following illustrations convey that complexity and depict the structures of the neck in detail from anterior and lateral perspectives:

●Anterior neck: (figure 2 and figure 3 and figure 4)

●Lateral neck: (figure 5 and figure 6)

Clinicians generally describe penetrating neck trauma according to the zone of injury, with the neck being divided into three zones (figure 1) [11].

Zone I is the most caudal and includes the base of the neck and thoracic inlet. It extends from the sternal notch and clavicles to the cricoid cartilage. Zone I contains the following structures:

●Thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins)

●Proximal carotid arteries

●Vertebral artery

●Apices of the lungs

●Trachea

●Esophagus

●Spinal cord

●Thoracic duct

●Thyroid gland

●Jugular veins

●Cranial nerve X (vagus nerve)

Zone II (midneck) continues cephalad from the cricoid cartilage to the angle of the mandible, and it contains the following structures:

●Common carotid arteries

●Internal and external branches of carotid arteries

●Vertebral arteries

●Jugular veins

●Trachea

●Esophagus

●Larynx

●Pharynx

●Spinal cord

●Vagus and recurrent laryngeal nerves

Zone III (upper neck) includes the region above the angle of the mandible up to the base of the skull and contains the following structures:

●Distal portion of the internal carotid arteries

●Vertebral arteries

●Jugular veins

●Pharynx

●Spinal cord

●Cranial nerves IX, X, XI, XII

●Sympathetic chain

●Salivary and parotid glands

Zone designation carries implications for management and prognosis. Zone I injuries can involve the mediastinum, where vascular control can be difficult. Zone III vascular injuries, especially those more cephalad, can also pose a significant surgical challenge.

Penetrating neck injuries (PNIs) can cross zone boundaries based on the implement or projectile and its angle of penetration Thus, an external wound in zone I can be associated with an internal injury in zone II or the mediastinum. Improved imaging using multidetector computed tomography with angiography (MDCT-A) has shown this to be the case [12].

The neck can also be thought of in terms of anatomic triangles (figure 7). The anterior triangle is bordered anteriorly by the midline, posteriorly by the sternocleidomastoid muscle, and superiorly by the lower edge of the mandible. The posterior triangle is located within the boundaries of the sternocleidomastoid muscle anteriorly, the clavicle inferiorly, and the anterior border of the trapezius muscle posteriorly. Most vital structures are located in the anterior triangle. Trauma to the posterior triangle, excluding the spine, carries a much lower likelihood of significant injury.

The neck has several fascial compartments. These compartments can help to contain bleeding from vascular injuries but can also lead to anatomic distortion in response to brisk bleeding. The most superficial fascia is located just below the skin and superficial to the platysma muscle. The platysma, which originates in the upper chest, extends superiorly over the clavicles and covers the anterolateral neck before attaching to the lower facial muscles. Violation of the platysma defines PNI. When the platysma is violated, a careful search for aerodigestive and neurovascular injury must be performed.

Deep to the platysma is the deep cervical fascia. This divides into prevertebral, pretracheal, and investing layers. The investing layer lies just deep to the platysma and encircles the entire neck, splitting to encase the sternocleidomastoid and trapezius muscles. The prevertebral fascia surrounds both the prevertebral muscles and cervical spine down to the chest. The pretracheal fascia attaches to the cartilaginous structures in the anterior neck (cricoid and larynx) before coursing inferiorly and deep to the sternum, ultimately inserting onto the sternum and pericardium. The location of this fascia allows the contents of a torn esophagus to spill into the mediastinum, which can result in mediastinitis. The carotid sheath is composed of all three layers of the deep cervical fascia. Within this sheath lie the carotid artery, internal jugular vein, and vagus nerve. One carotid sheath lies lateral to each side of the midline trachea. The esophagus is directly posterior to the trachea [13].

MECHANISM — Penetrating neck injuries (PNIs) commonly occur from guns, knives, and other impaling objects. Gunshot wounds are further divided into high- and low-velocity injuries. Bone penetration requires a velocity of approximately 350 feet (107 meters) per second. Because low-velocity weapons (eg, .22-caliber guns, other handguns, air guns) do not typically penetrate bone, they tend to produce a more erratic, unpredictable path through soft tissue, often following tissue planes. Military weapons and hunting rifles can fire at speeds over 2000 to 3000 feet (610 to 910 meters) per second and follow a more direct, predictable course through bone and soft tissue. High-velocity weapons can cause injury beyond the bullet track, a phenomenon called cavitation. This is related to the release of kinetic energy at impact. Entry and exit wounds caused by high-velocity weapons can appear innocuous, leading to an underestimation of the extent of tissue damage [14].

PREHOSPITAL CARE

General management — Any patient with a penetrating neck injury (PNI) can decompensate rapidly and should be transported immediately to the nearest trauma center. These patients often require airway management and emergency surgical intervention. Impaled objects should not be removed in the field.

Airway management in the patient with PNI can be difficult, and is discussed in detail below (see 'Airway management' below). Tracheal intubation is the primary approach to airway control when an immediate definitive airway is required. Bag-mask ventilation (BMV) can be used during transport to the emergency department. BMV can become problematic if an airway injury is present, as it can force air into soft tissue planes leading to anatomical distortion.

During transport, breath sounds should be auscultated and vital signs assessed frequently. Hypotension, tachypnea, unilaterally diminished breath sounds, and subcutaneous emphysema raise suspicion for a tension pneumothorax. Paramedics should perform needle thoracostomy if the patient is unstable and tension pneumothorax is suspected. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of needle/finger chest decompression'.)

En route to the trauma center, one or two large bore IVs (eg, 14 or 16 gauge) should be placed in the arm opposite the injury if possible. Active bleeding is controlled with direct pressure. Patients with bubbling or sucking neck wounds should ideally be placed in a head-down (ie, Trendelenburg) position on their left side in an attempt to prevent venous air embolism. Gauze impregnated with petroleum jelly should then be applied to the wound. The best position for the patient with a suspected arterial air embolus is less clear. Arterial emboli can cause cerebral edema thus a neutral position might be prudent and is recommended by the author. (See "Air embolism", section on 'Positioning the patient'.)

Cervical spine immobilization — We agree with the practice guidelines from the Eastern Association for the Surgery of Trauma (EAST), which state that immobilization of the cervical spine is only necessary when a neurologic deficit is present or a proper physical examination cannot be performed (eg, unconscious patient) and the mechanism is suspicious for a possible spinal cord or column injury [15]. Cervical spine injuries are uncommon with penetrating neck trauma, particularly stab wounds, and immobilization can hinder management in some cases by impeding visualization of the airway or by obscuring other injuries. (See "Cervical spinal column injuries in adults: Evaluation and initial management" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

A systematic review performed by the Prehospital Trauma Life Support Program concurs with this approach and goes on to emphasize that spine immobilization must not be performed at the expense of an accurate examination or the treatment of life-threatening conditions in a patient with penetrating trauma [16]. Patients in need of cervical spine immobilization who have difficulty breathing due to hemorrhage may need their stretcher placed on its side, or may need to sit upright while cervical spine precautions are maintained as best as possible. If a cervical collar is used, those with openings that allow for continuous observation of the neck are preferable.

In a large, retrospective study, the incidence of cervical spine fracture from gunshot wounds and stab wounds was 1.35 and 0.12 percent, respectively, while the incidence of cervical spinal cord injury from gunshot wounds and stab wounds was 0.94 and 0.11 percent, respectively [17]. Case series and reviews consistently report that any neurologic deficit from PNI was present at the time of emergency department presentation, suggesting that if neurologic deficit is not present on arrival in an evaluable patient, the likelihood of spinal cord injury or significant cervical fracture is remote [10,17-21].

CLINICAL FEATURES OF INJURY

General hard and soft signs — When evaluating a patient with a penetrating neck injury (PNI), it is imperative to look for hard and soft signs of injury (table 1). Hard signs reflect the presence of a serious injury that generally requires immediate transfer to the operating room.

Hard signs of vascular injury can include severe or uncontrolled hemorrhage, rapidly expanding or pulsatile hematoma, thrills and bruits, hypotension unresponsive to aggressive fluid resuscitation, absent or diminished radial pulse, and neurologic deficits consistent with cerebral ischemia (stroke). Hard signs of aerodigestive injury include air bubbling from a wound, massive hemoptysis, and respiratory distress. While there is disagreement about whether a large amount of subcutaneous air should be considered a hard or soft sign of aerodigestive injury, there is no doubt that it requires urgent evaluation.

Generally agreed upon soft signs of injury include proximity wounds (injury within 1 to 2 cm of a major vessel in the presence of other soft signs of vascular injury), minor hemorrhage, mild hypotension that responds to fluid resuscitation, minor hemoptysis or hematemesis, subcutaneous or mediastinal air, nonexpanding hematoma, dysphonia, and dysphagia.

Laryngotracheal injuries — Laryngotracheal injuries are predominantly confined to the cervical trachea. Such injuries can result in respiratory distress, stridor, subcutaneous air, hemoptysis, odynophagia, dysphonia, or anterior neck tenderness.

Vascular injuries — Vascular injuries can involve the carotid artery (common, internal, and external), the subclavian and vertebral arteries, thyroid vessels, and the vertebral, brachiocephalic, and jugular (internal and external) veins. Vascular wounds are not always obvious and, if missed, can lead to delayed complications such as pseudoaneurysm, rupture, and arteriovenous fistula. Look for obvious and subtle signs of injury. Obvious signs include shock, severe bleeding, decreased or absent peripheral pulses, global or focal neurologic deficits (eg, stroke), expanding hematoma, and bruits or thrills. Subtle signs include nonexpansile hematomas, mild bleeding, and transient hypotension that responds to fluid resuscitation. Intact pulses do not negate the possibility of vascular injury. Global neurologic deficits (eg, hemiplegia) can be caused by a vascular injury rather than a direct insult to the central nervous system. A patient with a normal physical examination who is otherwise asymptomatic is unlikely to have sustained a vascular lesion requiring surgical repair [22].

Pharyngoesophageal injuries — Pharyngoesophageal injuries are uncommon but are associated with high morbidity and mortality. They can be difficult to detect clinically and appear to be the leading cause of delayed death from neck trauma [15,23]. Clinicians should aggressively search for pharyngoesophageal injuries in patients with any suggestive signs using appropriate ancillary studies. There are no pathognomonic signs of esophageal injury, but dysphagia, blood in the saliva, hematemesis, and subcutaneous air suggest the diagnosis [23]. (See 'Emergency management' below.)

Nervous system injuries — PNI can involve the central nervous system (spinal cord) or the peripheral nervous system (cranial nerves VII though XII, sympathetic chain, peripheral nerve roots, brachial plexus). Spinal cord injury is uncommon, especially following low-velocity PNI (eg, stabbing). (See 'Cervical spine immobilization' above.)

High spinal cord injury can result in neurogenic shock with hypotension and bradycardia. Partial cord lesions create variable combinations of motor and sensory deficits depending on the location. The Brown-Sequard syndrome (lateral hemisection of the spinal cord) results in ipsilateral hemiplegia and contralateral loss of pain and temperature sensation. Hemiplegia occurs at the level of the injury, while the sensory deficits occur one to two levels inferiorly. Injury to the anterior spinal cord produces bilateral paralysis or motor deficits of variable severity, reflex changes, and bilateral loss of pain and temperature sensation, but proprioception is preserved. Dorsal spinal cord injury produces muscle flaccidity, hyporeflexia, ataxia, and loss of proprioception. (See "Anatomy and localization of spinal cord disorders".)

Peripheral or cranial nerve injuries may not be obvious unless a careful neurologic examination is performed. When possible, assess the patient's speech (cranial nerves IX, X, and XII), movement of the palate (cranial nerves IX and X) and tongue (cranial nerve XII), and shoulder shrug (cranial nerve XI). These functions involve the cranial nerves most frequently injured. Cranial nerve VII may be injured with PNI near the angle of the mandible. It is important to assess facial nerve function early. A deficit detected upon arrival implies a nerve transection, while a deficit that develops over the ensuing hour or two suggests neurapraxia from blunt injury or nerve compression from a hematoma or significant soft tissue swelling. A watch-and-wait approach as opposed to urgent surgical repair may be indicated if transection is unlikely, but surgical consultation should be obtained regardless.

Horner syndrome occurs with injury to the sympathetic chain and produces ipsilateral miosis with ptosis of the upper eyelid and anhidrosis of the ipsilateral side of the face. It is seen most commonly with zone I injuries.

EMERGENCY MANAGEMENT

General approach — Every penetrating neck injury (PNI) must be inspected (but not probed) to determine if the platysma muscle has been violated. An intact platysma indicates that the wound is superficial, while violation by definition constitutes a PNI. Platysma violation and the patient's symptoms and signs determine how to proceed with management. We recommend surgical consultation for all PNIs.

Unstable patients, including those with airway injury requiring immediate intervention, hemodynamic instability, or other severe injury from their penetrating neck wound, are resuscitated and transferred expeditiously to the operating suite. Emphasis is on rapid stabilization of the airway, breathing, and circulation. The general management of trauma patients is discussed separately. (See "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child".)

Stable patients with a PNI are monitored closely while diagnostic evaluation proceeds. Clinicians should remain alert for delayed presentations of airway compromise, worsening hemorrhage, or other occult injuries (table 1). The emergency clinician often initiates the search for laryngotracheal, vascular, and pharyngoesophageal injuries as indicated, following the initial trauma evaluation.

The approach differs if the patient arrives at a facility where surgical consultation or diagnostic studies are limited or unavailable. In such cases, expeditious transfer to a trauma center is often warranted. For unstable patients, such transfer is acceptable, once the airway is stabilized and basic resuscitation is performed to the extent possible, if life-saving interventions can only be performed at another facility. A paramedic or some other advanced clinician capable of providing care and airway management during transport must accompany the patient. For the hemodynamically stable patient with signs of injury that suggest a possible need for acute surgical intervention, transfer to a level 1 or 2 trauma center should be arranged as soon as a stable airway is assured. In such instances, additional diagnostic studies are best deferred to the receiving hospital so as not to delay transport. It is reasonable for hemodynamically stable patients without hard signs of injury (table 1) and a negative computed tomography (CT) angiogram (assuming this can be performed) to remain at the initial facility for observation and serial re-examination in the event that a trauma center is not available.

Although careful physical examination identifies most arterial wounds, it may not detect some important injuries, particularly those involving the esophagus. Venous injuries too may be missed. Clinicians should perform appropriate diagnostic imaging if there is any reasonable suspicion for occult injury or the patient presents with soft signs of injury. The diagnostic workup of the stable PNI patient, including the studies needed to assess specific injuries, is discussed below. (See 'Diagnostic strategies for specific scenarios and injury types' below.)

Initial evaluation and interventions — Patients with PNI may initially appear stable but can decompensate rapidly. Surgical consultation should be obtained for all PNIs unless the wounds are determined to be superficial, meaning the platysma muscle was not violated. A no-zone algorithm for wounds that penetrate the platysma is provided (algorithm 1).

Penetrating neck trauma must be approached systematically. Immediately assess the airway of any patient with PNI. Assessment can be difficult, particularly deciding whether the patient requires early intubation. Although no consensus exists, most experts advocate immediate intubation in patients with evidence of significant injury or respiratory difficulty (eg, subcutaneous air, airway compromise, significant bleeding or hematoma, voice alteration, stridor) [24,25]. (See 'Airway management' below.)

Once the airway has been stabilized, inspect and auscultate the chest, keeping in mind that PNIs, particularly those in the lower neck (zone I), can damage intrathoracic structures (eg, lung and great vessels). Unilaterally decreased breath sounds or palpable subcutaneous emphysema suggests pneumothorax. Emergency department ultrasound should be used to look for evidence of pneumothorax in such instances. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pleural examination'.)

Next, assess pulses and vital signs. Apply direct pressure to bleeding wounds. In almost all cases, the wound should not be explored in the emergency department. For life-threatening bleeding from a neck wound that does not stop with direct pressure, the clinician can insert a Foley catheter into the wound and fill the balloon with 10 to 15 mL of saline or until resistance is felt [26,27]. This may temporarily tamponade bleeding until definitive treatment is available. If bleeding is severe, neither direct pressure nor a Foley catheter effectively controls the hemorrhage, and no surgeon is available, the emergency clinician may have no choice but to attempt to explore the wound and control bleeding by other means (eg, placing a clamp).

Place all PNI patients on continuous cardiac and pulse oximetry monitoring, with supplemental oxygen as needed to maintain the oxygen saturation above 92 percent. Two large-bore (eg, 14- or 16-gauge) intravenous lines should be placed contralateral to the injury if possible, as ipsilateral venous injuries may exist.

Studies of penetrating neck trauma specifically in civilians that examine the effectiveness of tranexamic acid (TXA) or advanced hemostatic bandages are not available. Nevertheless, observational studies describe successful use of these tools and reduced mortality in combatants with severe hemorrhage from penetrating trauma [28-30]. A patient with a PNI and active hemorrhage who presents within three hours of injury should receive TXA according to local treatment protocols. Despite previous concern of thrombotic events from TXA, a meta-analysis found no increase in clotting complications from TXA [31]. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Patient within three hours of injury'.)

Blood should be collected and sent for appropriate testing. The tests to obtain vary with clinical circumstance but usually include:

●Type and cross-match blood in preparation for possible transfusion

●Prothrombin time with international normalized ratio

●Serial hemoglobins

●Blood urea nitrogen, serum creatinine, glucose, and electrolytes

●Complete blood count

Cardiac arrest in the setting of PNI is an indication for emergency thoracotomy. Potential causes of arrest include hemorrhagic shock, tension pneumothorax, airway compromise, cardiac tamponade, and air embolism. Emergency department thoracotomy is discussed separately. (See "Approach to shock in the adult trauma patient".)

Unstable patients with active hemorrhage or other hard signs of injury (table 1) are definitively managed in the operating room. Those with findings suggestive of major vascular injury, who are hemodynamically stable, may be taken directly to the angiography suite for possible embolization or definitive diagnosis rather than the operating room. Stable patients with soft signs of injury can be evaluated further in the emergency department. Hard and soft signs of injury are described above. (See 'Clinical features of injury' above.)

Stable patients should be closely monitored throughout their evaluation. Perform frequent re-examinations and watch closely for signs of injury to the larynx, trachea, pharynx, esophagus, carotid arteries, jugular veins, lower cranial nerves, brachial plexus, and spinal cord. A table summarizing key elements of a serial physical examination for PNI patients is provided (table 2).

Although careful physical examination identifies most arterial wounds, it may not detect other important injuries, particularly those of the esophagus. Venous injuries can also be missed. Left neck trauma can rarely involve the thoracic duct. Although uncommon, the thyroid gland can be injured, as can other submandibular glands. Lower neck wounds can cause injury to thoracic structures, including the aorta, a mainstem bronchus, and the lungs. Clinicians should perform diagnostic imaging if there is the slightest concern about occult injury.

A careful primary and secondary trauma survey should be performed looking for other injuries. Consider concomitant injuries as a source of patient distress. Perform a careful neurologic examination, looking for gross deficits and less obvious signs of cranial or peripheral nerve injury. General assessment of the trauma patient is discussed separately. (See "Initial management of trauma in adults".)

Airway management — Direct or suspected injury to the airway typically requires immediate airway protection. Airway management in these patients can be difficult. A systematic approach is needed and must address the following questions (algorithm 2):

●Does the patient require immediate airway protection?

●What is the best approach and technique for airway protection?

Patients with PNI in obvious distress (eg, respiratory distress, severe hemorrhage, extensive or sucking neck wound, shock) require immediate stabilization of the airway. Other patients with neck trauma may require airway protection based on the projected course of their injuries or evidence of deterioration. A general discussion of how to approach the difficult airway is provided separately. (See "Approach to the difficult airway in adults for emergency medicine and critical care".)

Signs that strongly suggest the need to secure the airway immediately in patients with significant facial or neck trauma include:

●Significant bleeding or neck hematoma

●Hemoptysis

●Subcutaneous neck emphysema

●Bruit or thrill

●Distorted neck anatomy

●Stridor

●Difficulty or pain when swallowing secretions

●Abnormal voice, especially hoarseness ("hot potato voice")

When the airway is threatened but anatomic structures and relationships are preserved, rapid sequence intubation (RSI) is appropriate to establish an airway [18,32]. One retrospective review of airway management in patients with PNI performed at a major urban trauma center found RSI to be a safe and effective approach for many patients [33], and other centers have reported similar results [34]. In-line stabilization of the cervical spine by an assistant is indicated if spinal injury is suspected, although spine injuries are uncommon with PNI. Rescue airway devices can be used if placement of a tracheal tube is unsuccessful as long this does not delay the establishment of a needed surgical airway. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and 'Cervical spine immobilization' above.)

RSI should not be used and a surgical airway is generally recommended when massive facial or neck trauma that distorts anatomic landmarks, hemoptysis, hematemesis, or obstruction above the larynx is present and is likely to make effective ventilation or successful placement of a tracheal tube unlikely.

Neuromuscular paralysis is often unnecessary when penetrating injury causes partial or complete transection and exposure of the trachea. In these cases, the caudad portion of the exposed trachea can be stabilized with a towel clip or clamp and intubated directly. Frothing or large air bubbles emanating from a neck wound raises concern for this possibility.

If tracheal intubation is deemed necessary in an initially stable patient based upon the projected clinical course, and the airway is predicted to be difficult because of distorted anatomy, the clinician may elect to use an "awake" technique. This entails the use of topical anesthesia and light sedation to enable direct or flexible endoscopic laryngoscopy and intubation, if conditions are favorable. When direct airway injury is suspected (eg, subcutaneous air is present in the soft tissues of the neck), a flexible endoscopic guided oral intubation may be the best approach, if available, because it enables the clinician to determine the integrity of the interior of the airway above and below the vocal cords [35]. The "awake" technique is discussed separately. (See "Approach to the difficult airway in adults for emergency medicine and critical care", section on 'Awake techniques'.)

We recommend simultaneous preparation for RSI, non-surgical rescue device (eg, an extraglottic device), and a surgical airway (ie, triple setup) if an "awake" technique is used. Some clinicians suggest avoiding an "awake" technique because of concerns that it can precipitate airway collapse, but this assertion is unproven.

The best method to achieve definitive airway control in the setting of PNI will vary according to clinical circumstances, clinician skill, and hospital resources [34]. Nevertheless, the following concepts generally apply:

●Avoid techniques not performed with visualization, whether direct, endoscopic, video, or some other technique. Blind placement of a tracheal tube into a lacerated tracheal segment can create a false lumen outside the trachea or convert a partial tracheal laceration into a complete transection. Blood and secretions make flexible endoscopic approaches more challenging.

●Be prepared for unexpected difficulty. Have available and ready for use at least two suction devices, a range of different-sized tracheal tubes, rescue airway devices, and a surgical airway kit. We recommend a triple setup for patients with PNI in whom tracheal intubation is attempted. Patients with neck trauma can deteriorate quickly and may have abnormalities that complicate tracheal tube placement but are not apparent externally.

●Bag-mask ventilation (BMV) to preoxygenate in preparation for RSI or to reoxygenate following a failed attempt at intubation may force air into injured tissue planes and distort airway anatomy. Although it is appropriate to perform BMV to oxygenate patients when necessary, ventilation should be performed with vigilance, and not overaggressively, to ensure it is not creating more harm than benefit. (See "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Preoxygenation'.)

Invasive airway management (eg, cricothyroidotomy) represents the standard approach when tracheal intubation, by any method, is unsuccessful or contraindicated. Indications for a surgical airway include massive upper airway distortion, massive midface trauma, and inability to visualize the glottis because of heavy bleeding, edema, or anatomic disruption. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

Cricothyrotomy can be difficult in a patient with distorted neck anatomy. The procedure is relatively contraindicated if an anterior neck hematoma exists or a laryngeal injury is suspected but may be the only viable option in some patients with PNI. If the necessary resources and expertise are readily available, patients whose external landmarks are sufficiently distorted to make cricothyrotomy difficult or impossible are generally intubated awake using a flexible intubating scope. If the clinician suspects partial or complete laryngeal transection, a flexible endoscopic approach or a tracheostomy inferior to the injury may be necessary.

Needle cricothyroidotomy with percutaneous transtracheal ventilation (with bag-valve mask or wall oxygen as the delivery source) can provide oxygen to adult and pediatric patients while arrangements are made to establish a definitive airway. Clinicians must take care to avoid catheter misplacement or dislodgement, which can force air into the tissues and distort normal airway anatomy. Percutaneous transtracheal ventilation should not be performed if laryngeal fracture, tracheal rupture, or tracheal transection are suspected. The technique can be useful in children ≤10 years in whom open surgical cricothyrotomy is contraindicated. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

Blind nasotracheal intubation is generally not considered an appropriate technique in patients with PNI. Blind nasotracheal intubation can exacerbate preexisting airway injury and may cause vomiting and aspiration, turbinate injury, elevated intracranial pressure, bleeding, and (in awake patients) cervical spine motion from discomfort [36]. However, some have questioned this proscription. One retrospective study reported on 36 of 40 patients with PNI who were successfully intubated in the field using blind nasotracheal intubation [37].

Physical examination — In addition to the standard primary survey conducted for all patients with significant trauma, the examination of the patient with PNI focuses on identification of any hard or soft signs associated with injury to important structures (table 1). The primary survey and signs of PNI are reviewed in detail separately. (See "Initial management of trauma in adults", section on 'Primary evaluation and management' and 'Clinical features of injury' above.)

Whether physical examination can reliably detect significant visceral or vascular injuries from penetrating neck trauma remains a source of debate. Two prospective studies underscore this difference of opinion. The first evaluated 393 consecutive patients with PNI and found that 30 percent had significant injuries discovered during surgical neck exploration despite no evidence of such injury during the initial examination [38]. In contrast, a second study of 223 patients with PNI concluded that careful examination using a standardized protocol that identified objective signs of injury (eg, large expanding hematomas, severe active bleeding, shock not responding to fluids, diminished radial pulse, bruit) reliably predicted major vascular trauma requiring treatment [1]. Subsequent studies have since validated the reliability of the physical examination in excluding vascular injury in stable patients with PNI [22,39-41]. Additional studies suggest physical examination is accurate at detecting esophageal injury [15,42,43].

SURGICAL ASSESSMENT

Anatomic zone-based versus no-zone management — The management of penetrating neck injuries (PNIs), particularly in stable patients, has remained a source of debate among trauma surgeons for decades. Given the controversies about the management of PNI, limited evidence base, and variability in resources and experience, decisions about whether to use a selective, zone-based management approach or a no-zone approach will vary by local expertise and resources and are likely to remain institution specific for the time being [44,45]. A brief summary of the history of the management of PNI is provided below. (See 'Evolution of the surgical approach to PNI' below.)

The relatively high rates of negative surgical exploration associated with the algorithmic, zone-based approach coupled with improvements in diagnostic imaging technology, particularly multidetector computed tomography with angiography (MDCT-A), have led many trauma centers to discard anatomic zone-based protocols for the management of PNI in favor of a "no-zone" approach [46,47]. No-zone management algorithms are based on patient stability and the presence of soft versus hard signs of injury, regardless of injury location (ie, the zone of the neck involved (figure 1)), whereas zone-driven approaches are based on the location of the external wound. Unstable patients are transferred rapidly to the operating room. Those who are stable but symptomatic undergo MDCT-A, the results of which, in combination with examination findings, determine whether further diagnostic studies, surgical intervention, or both are indicated.

MDCT-A has high sensitivity and specificity for laryngotracheal and vascular injuries, and identifies many pharyngoesophageal injuries, thereby eliminating the need for multiple imaging studies to assess each type of injury [48]. In addition, MDCT-A enables clinicians to assess signs of injury situated close to important internal structures (so-called "proximity wounds") and determine whether these are high or low risk, thereby allowing for better informed decisions concerning the need for observation, further diagnostic evaluation, or surgical exploration. (See 'Diagnostic strategies for specific scenarios and injury types' below.)

Studies using MDCT-A in the assessment of PNI patients have shown that important discrepancies frequently exist between the location of the entry wound and the structures injured. Cutaneous wounds often do not correlate with deeper injury locations, and entry wounds in one zone may be associated with severe injuries in adjacent zones. As an example, one prospective study found that one in five surface wounds located in zone II extended across zone I or zone III internally [12]. Furthermore, when multiple neck wounds are present in more than one region, zone-driven protocols become unclear. Perhaps most importantly, use of a zone-based approach in stable, symptomatic patients has led to a high rate of negative surgical exploration in zone II injuries. Concerns with the no-zone approach include limitations of MDCT-A for detecting pharyngoesophageal injuries, which are potentially life threatening if missed.

Evolution of the surgical approach to PNI — Before World War II, all PNIs were treated expectantly ("watch and wait"), resulting in mortality rates as high as 35 percent [3]. In an attempt to reduce the unacceptably high death rates associated with PNIs, a mandatory surgical approach was adopted, and exploratory surgery was performed in all patients with PNI. This approach reduced mortality rates substantially [4] and remained widely accepted until well into the 1990s, when it became clear that despite improved outcomes, mandatory surgery led to unacceptably high negative exploration rates [38].

High negative exploration rates led to the development of an anatomic zone-based (figure 1), selective surgical approach for stable patients with PNI that allowed for a range of diagnostic and therapeutic options based on which zone of the neck was injured and the stability of the patient. The zone-driven selective surgical approach was based in part on the relative ease with which surgeons could access zone II (mid-neck) injuries compared with the more technically challenging zone I and III injuries. Early algorithms for stable patients favored mandatory surgery for zone II injuries, while further diagnostic studies preceded operative intervention for zone I and III wounds. Much debate followed as to the best approach for symptomatic, stable patients [3,8,49]. One persistent controversy was whether all zone II PNIs required surgical exploration or whether selected patients could be managed nonoperatively.

During the 1990s and early 2000s, most research and many trauma surgeons came to favor some form of selective management. One early review concluded that zone II injuries had similar outcomes regardless of whether mandatory surgery or selective management was pursued, and subsequent research supported a selective approach [27,49-52]. Practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) in 2008 concluded that both approaches were justifiable and safe [15].

As computed tomography (CT) has become more widely available and its resolution and speed have improved, it has become the study of choice for investigating PNI. Improved imaging has made it clear that many wounds with a single entry point actually traverse more than one zone. This has led many surgeons to use a "no-zone" management strategy, which is described above.

DIAGNOSTIC STRATEGIES FOR SPECIFIC SCENARIOS AND INJURY TYPES

Stable patient with soft signs of injury — Several major trauma organizations and many trauma specialists advocate using multidetector computed tomography with angiography (MDCT-A) as the first-line study for initial evaluation of stable patients with a penetrating neck injury (PNI) who exhibit any soft sign of internal injury due to its high sensitivity and specificity, speed, and widespread availability [15,48,53-58]. We agree that imaging with MDCT-A is an important part of the initial workup, in combination with physical examination and a plain chest radiograph. Additional diagnostic imaging or surgical exploration is performed if the patient deteriorates or more concerning signs of injury are identified. (See 'Definitive management' below.)

For patients with PNI in whom soft signs are present but the initial workup (ie, physical examination, plain chest radiograph, and MDCT-A) reveals no sign of internal injury, we suggest that the patient be observed for 24 hours either by or in consultation with a trauma service. No ideal interval has been established, but for low-risk patients, it is prudent to perform a repeat examination every six hours [59]. Reevaluation should include, when feasible, an interview to determine whether new symptoms have developed and a systematic physical examination, and it is best performed using a standardized format (eg, checklist). A table summarizing key elements of a serial physical examination for PNI patients is provided (table 2).

In resource-limited settings without MDCT-A, standard angiography, or requisite surgical expertise, we suggest stabilizing the patient as best as possible and then transporting to the nearest facility with the equipment and personnel necessary for a thorough evaluation of PNI. This is necessary in all patients with hard signs of injury, but we suggest this approach for patients with any soft signs as well.

Stable, asymptomatic patient — Patients with a genuine PNI (platysma is penetrated) but who remain free of any signs or symptoms of internal injury are initially managed similarly to stable patients with soft signs of injury. Debate continues as to whether serial physical examination alone is adequate to assess such patients or whether MDCT-A should be used as a first-line diagnostic investigation. We support the use of MDCT-A to screen for injuries.

Studies that suggest serial physical examination alone is adequate are often performed at large trauma centers with a high patient volume. Clinical examination without advanced imaging may not be feasible at smaller facilities with less experience or fewer clinicians. The decision to perform or forego MDCT-A is best made using an appropriate management algorithm that accounts for the local institution's resources or in consultation with a trauma surgeon.

In the setting of a completely asymptomatic patient with no hard or soft signs of injury at a facility lacking MDCT-A, angiography, and/or surgical capability, it may be reasonable to observe the patient closely in a monitored setting for 24 hours in the event that there is no nearby trauma center. Transfer to a higher level of care is warranted if any signs of injury develop or the patient's condition deteriorates in any way.

Laryngotracheal injury — Multidetector computed tomography (MDCT) is the imaging modality of choice when looking for laryngotracheal injuries in stable patients with PNI. MDCT provides anatomic detail about laryngeal integrity and is useful when cervical spine immobilization is necessary [60]. Studies describing the test characteristics of MDCT for detecting laryngotracheal injuries sustained from penetrating neck trauma are limited, but sensitivity and specificity are thought to be high.

Thin-slice (1 to 2 mm) MDCT provides better images of mineralized cartilage than plain radiographs, although plain films should be inspected for signs of cartilaginous fracture and extraluminal air if obtained. The most common complaint associated with cartilaginous fractures is hoarseness, but dyspnea, hemoptysis, globus sensation, ecchymosis, hematoma, crepitus, and pain may be present. None of these signs and symptoms is predictive of injury severity.

MDCT has some limitations. Degloving injury of the cartilage with denuded mucosa can be missed, as can certain types of laryngotracheal separation and mucosal perforation. Pediatric cartilaginous structures are poorly calcified and may be more difficult to visualize than an adult larynx. Streak artifact from metallic foreign bodies can obscure visualization of structures. However, in most cases, injuries missed by MDCT do not require operative repair, including minor edema, hematoma, minor denuded cartilage, and nondisplaced fractures [60].

Further studies may be necessary in patients with clinical signs of injury or those at high risk for occult injury whose initial imaging, including MDCT, is nondiagnostic. Flexible nasopharyngoscopy and laryngoscopy provide additional methods for assessing laryngotracheal trauma. Endoscopy enables thorough evaluation when scatter artifact from metallic objects obscures computed tomography (CT) images.

Flexible nasopharyngoscopy allows visualization of the hypopharynx and supralaryngeal structures in an awake or sedated patient, while flexible laryngoscopy allows evaluation of the larynx. Rigid endoscopy allows for evaluation of the distal airway but requires general anesthesia.

Vascular injury — Evaluation of suspected vascular injury in patients with PNI will vary based on institutional preferences and resources. Options include MDCT-A, standard angiography, duplex ultrasound, and possibly magnetic resonance angiography (MRA). MDCT-A demonstrates sensitivity and specificity approaching 100 percent for detecting vascular injury and is widely considered the first-line imaging study in stable patients with soft signs of injury [55,61,62]. Conventional angiography may be needed if metallic debris obscures bullet trajectory and anatomic detail on CT. Duplex ultrasound is operator-dependent but has been shown to have high sensitivity and specificity in experienced hands for identifying vascular injuries [63-65]. Studies other than MDCT-A are generally best performed in consultation with the trauma surgeon and radiologist to ensure an appropriate and efficient workup.

In the past decade, MDCT-A has widely replaced conventional angiography for the initial evaluation of suspected vascular injury in stable patients with PNI. It has been incorporated into many trauma protocols as the initial imaging modality of choice. One prospective study of 453 patients with PNI reported 100 percent sensitivity and 97.5 percent specificity of MDCT-A for identifying clinically significant injuries [55]. Aside from its accuracy detecting vascular injuries, MDCT-A has the added benefits of wide availability (around the clock at most hospitals), speed of performance (the entire neck can be scanned in minutes), and ability to detect nonvascular injuries [53,66,67]. In patients with a history of hypersensitivity to radiocontrast media, alternative methods of diagnostic imaging may be needed, and radiology should be consulted to determine the best approach. (See "Diagnosis and treatment of an acute reaction to a radiologic contrast agent" and "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Patients with past reactions to contrast'.)

Angiography demonstrates sensitivity and specificity of close to 100 percent and has been considered the gold standard in stable patients for decades [68]. It may be the best study to diagnose certain vascular injuries, especially if procedures such as embolization or stent placement are anticipated or when artifacts obscure CT images of the vasculature. Suspected distal carotid artery lesions may be better assessed using angiography as less invasive studies have limitations in that region. Some have argued that arteriography enables better surgical planning, but this concept is largely obsolete [66,68-70].

Two- or four-vessel angiography is costly and invasive (complications occur in approximately 2 percent of patients) and consumes a great deal of resources. Additionally, angiography may not be available at all hospitals and at all times. These factors, combined with the high number of negative studies and advancements in MDCT-A technology, have led many trauma specialists to use noninvasive tests coupled with careful physical examination for the initial evaluation of possible vascular neck injuries [1,71,72]. If chosen, angiography should include the carotid and vertebral vessels, the intracranial portion of the carotid artery in zone III injuries, and the aortic arch with its branches in zone I injuries.

Duplex ultrasound is fast, noninvasive, and inexpensive, but highly operator dependent. In combination with a careful physical examination, duplex ultrasound can detect or suggest the presence of vascular injury and may represent an alternative to angiography in select patients [63,64]. In one prospective study of 82 patients with PNI, the combination of careful physical examination using a written protocol and duplex ultrasound detected 10 of the 11 vascular injuries identified by conventional angiography, and both injuries that required surgical repair [65]. Similar results in additional prospective studies suggest that a combination of an unremarkable physical examination performed according to a standard protocol, negative plain chest radiograph, and negative duplex ultrasound can effectively rule out significant vascular injury, defined as a lesion requiring surgical repair [1,46,63].

Duplex ultrasound has limitations, including an inability to image the distal intracranial portions of the carotid artery and portions of the vertebral artery and the proximal subclavian vessels. In addition, duplex ultrasound may not accurately detect pseudoaneurysms and artifact (eg, from bony fractures, metallic foreign bodies, subcutaneous air), which can obscure vascular structures. Lastly, subcutaneous air in the soft tissues can limit the exam.

MRA is not a first-line study to detect vascular injury following penetrating neck trauma. There are no large, prospective studies comparing MRA with conventional angiography or to MDCT-A. MRA has several drawbacks, including lack of availability and longer scan time. Monitoring of the patient is also more difficult during the performance of the study.

Pharyngoesophageal injury — Although relatively uncommon, penetrating esophageal injuries are notoriously insidious, and delays in diagnosis carry mortality rates as high as 20 percent [8,23,25]. Delays over 24 hours further increase the mortality rate. If pharyngoesophageal trauma is suspected, MDCT alone is inadequate for definitively ruling out injury, although it often identifies some sign of injury [73]. In some studies, the sensitivity of MDCT for pharyngoesophageal injury is reported to be as low as 53 percent [43,74]. Direct esophageal studies (eg, contrast swallow and endoscopy) can provide a diagnosis and are reported to have a sensitivity of nearly 100 percent.

Given potential difficulties in diagnosis and the consequence of delays, many trauma specialists obtain imaging studies to rule out esophageal injury in all cases of PNI associated with soft signs of esophageal injury or wounds close to the pharynx or esophagus (so-called "proximity wounds"). MDCT is typically the initial study performed because it detects laryngotracheal, vascular, and some esophageal injuries simultaneously and rapidly. In addition, if a pharyngoesophageal injury is not directly identified, proximity wounds prompt the treating physician to order definitive studies to exclude violation of the pharynx or esophagus.

A plain neck or chest radiograph showing retropharyngeal air or pneumomediastinum, respectively, suggests esophageal injury, but neither test is specific. In such cases, immediate surgical consultation should be obtained to determine management or the choice of subsequent imaging should the patient not proceed immediately to the operating suite.

Practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) suggest that either endoscopy of the esophagus or esophagography can be used to rule out significant esophageal injury in stable patients with PNI [15]. If the patient can cooperate, a Gastrografin or thin barium swallow can be performed first, and if nondiagnostic, flexible esophagoscopy can be performed, increasing sensitivity to nearly 100 percent [15,59].

DEFINITIVE MANAGEMENT

Consultation and disposition — Patients with a penetrating neck injury (PNI) can be categorized as unstable with signs reflecting severe injury (eg, stroke, airway obstruction, shock), stable with soft signs or symptoms suggesting injury (eg, dysphagia, nonexpanding hematoma, minor bleeding), or asymptomatic.

Unstable patients and those with hard signs of significant injury are taken immediately to the operating room for definitive treatment [15,56]. Despite essentially all literature on this topic supporting immediate neck exploration in any patient with hard signs of vascular injury, there is a subgroup that might benefit by a slightly different pathway. Some have recommended, in a select group with hard signs of vascular injury (eg, expanding hematoma, bruit, thrill) who are hemodynamically stable, that a multidetector computed tomography with angiography (MDCT-A) may be beneficial prior to neck exploration as treatment may be interventional rather than operative. Asymptomatic patients should be observed and evaluated with serial physical examinations or institution-specific protocols involving ancillary diagnostic studies such as MDCT-A. Multiple observational studies suggest that asymptomatic patients with PNI can be managed nonoperatively with serial examination [22,55]. We recommend immediate surgical consultation for all cases of PNI and placement of the asymptomatic patient in a monitored setting for close observation lasting a minimum of 24 hours.

Controversy arises with the management of stable PNI patients manifesting soft signs of injury. MDCT-A is a powerful diagnostic tool and the initial study of choice for essentially all of these patients pending contraindications [54,56]. Additional testing is often based upon MDCT-A findings. As an example, a high (zone III) vascular lesion evident on MDCT-A may mandate conventional angiography and stent placement. If the MDCT-A is indeterminate for aerodigestive tract injury (eg, computed tomography [CT] reading: "air bubbles seen; cannot exclude aerodigestive injury"), further evaluation (eg, esophagography, endoscopy) is indicated. Definitive management in such cases will vary according to clinical circumstance, local surgical practice, and hospital resources. We recommend transfer to a trauma center for any patient at risk for significant injury.

Specific injuries

●Laryngotracheal injury – A large proportion of patients with traumatic airway injuries require definitive airways [75,76]. Tracheal intubation using rapid sequence intubation (RSI) is safe in the majority of patients, although exceptions exist [33]. Airway management is discussed in detail above. (See 'Airway management' above.)

Timely repair of certain laryngotracheal injuries is important to prevent long-term complications such as chronic pain, stenosis, or voice change.

●Pharyngoesophageal injuries – All suspected pharyngoesophageal injuries (PEIs) warrant early surgical consultation. Most PEIs are treated surgically, but select patients may be managed nonoperatively [8].

If not promptly diagnosed, PEI can cause mediastinitis and abscess or empyema formation from the leakage of gastric contents. Clinicians should begin treatment with broad-spectrum antibiotics in all patients with possible PEI. Although some trauma specialists advocate decompressing the stomach with a nasogastric tube, performing a blind procedure in a patient with PEI entails significant risk [4]. We do not believe this procedure should be performed blindly in the emergency department.

Prophylactic antibiotics are generally not indicated in penetrating trauma unless there is a hollow viscous injury such as PEI, the wound is grossly contaminated, or surgical exploration is performed. Tetanus prophylaxis should be administered as necessary. (See "Overview of inpatient management of the adult trauma patient", section on 'Prophylaxis and preventive care' and "Infectious complications of puncture wounds", section on 'Tetanus immunization'.)

●Vascular injuries – Immediate consultation with a vascular surgeon should be obtained if vascular injury from a PNI is suspected. A trauma or thoracic surgeon may be needed and should be consulted if a zone I vascular injury is suspected.

A range of surgical and interventional options exist for the management of vascular injury, including embolization, ligation, stent placement, surgical repair, and revascularization. Early revascularization offers the best chance for successful outcome when managing injuries to the carotid artery [4,68,77,78]. Coma portends a poor outcome. Inability to differentiate coma due to vascular injury leading to stroke-like symptoms from blunt central nervous system trauma or drug or alcohol intoxication confuses the clinical picture and complicates management.

●Neurologic injuries – Cervical spine injury is uncommon following penetrating trauma to the neck. A retrospective review of a large trauma database found the incidence of cervical spine fracture to be 1.35 percent with gunshot wounds and 0.12 percent with stab wounds to the neck. The incidence of spinal cord injury was even lower. All patients with cervical spinal cord injury had a neurologic deficit at initial presentation. Multidetector computed tomography (MDCT) and possibly magnetic resonance imaging (MRI) are useful for the diagnosis of these injuries [17].

Pediatric considerations — The incidence of PNI in children is substantially lower than in adults (0.3 versus 5 to 10 percent) [79]. In general, the presentation and management of the pediatric patient with a PNI are the same as in adults [80]. Of note, in infants and younger children, the standard anatomic neck zones do not readily apply. Guidelines for the transport of children with PNI may vary by location and are likely different than those for adults [81]. Transfer to a hospital with expertise managing pediatric trauma is ideal. Prior to transport, airway stabilization should be assured. In addition, careful inspection for both global and focal neurologic deficits should be performed whenever possible, as such injuries may be less apparent in pre-verbal children.

A number of imaging modalities, including MDCT-A, ultrasonography, magnetic resonance angiography (MRA), and conventional angiography, can be used to exclude vascular injury in both adults and children. At most institutions, MDCT-A is considered the standard test for the initial evaluation of any patient without indications for immediate operative intervention but with soft signs of injury. Because there are so few pediatric patients with PNI, there is little evidence to guide management, and recommendations are based on adult studies [79,82].

In stable patients being managed at centers experienced with PNI and MRA, this approach to diagnostic imaging may be preferable in order to limit radiation exposure. However, limited availability, length of the procedure, the need for sedation in any uncooperative or frightened child, and difficulty monitoring the airway may make this approach less attractive. MRA may be useful in the child with PNI who is otherwise completely asymptomatic. Such decisions about diagnostic imaging should be made in consultation with the pediatric trauma surgeon and radiologist.

Pitfalls and pearls

●Concentrate on imminent and delayed signs of airway compromise. Do not allow dramatic thoracoabdominal injuries to distract from essential airway management.

●Be prepared to provide a surgical airway immediately if attempts at oral intubation fail. Use a triple setup.

●Wounds to the distal carotid artery can cause neurologic deficits that mimic stroke, spinal cord injury, or head injury. Investigation of possible neurovascular injury must be performed in any altered or unconscious patient with neurologic deficits and a negative CT head.

●Zone I injuries can involve life-threatening thoracic injuries.

●Maintain high concern for occult esophageal injuries (these may be missed by MDCT), which can cause life-threatening sequela.

●Never delay surgical consultation.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Penetrating neck injury" and "Society guideline links: Cervical spine injury" and "Society guideline links: General issues of trauma management in adults".)

SUMMARY AND RECOMMENDATIONS

●Anatomy – Injuries that penetrate the platysma are considered penetrating neck injuries (PNIs). These are generally divided into three zones according to location (figure 1). Mortality in patients with PNI appears to be highest with zone I injuries (below the cricoid cartilage), which can also involve adjacent intrathoracic structures. (See 'Epidemiology' above and 'Anatomy' above.)

●Prehospital care – Any patient with a PNI can decompensate rapidly and should be transported immediately to the nearest trauma center, if possible. Impaled objects should not be removed in the field. Bag-mask ventilation (BMV) can become problematic if an airway injury is present and air is forced into soft tissue planes, leading to anatomical distortion. Cervical spine injury from PNI is uncommon, and immobilization is not necessary in many instances. (See 'Prehospital care' above.)

●Initial evaluation and intervention – Initial management follows standard trauma protocols in most institutions. Obtain emergency surgical consultation for all PNIs, aside from obviously superficial injuries. Unstable patients should receive definitive care in the operating suite (algorithm 1). Do not explore neck wounds in the emergency department. Traumatic arrest in the emergency department is an indication for emergency thoracotomy in patients with PNI. (See 'Initial evaluation and interventions' above.)

●Airway management – Patients with PNI in obvious distress (eg, respiratory distress, severe hemorrhage, extensive or sucking neck wound, shock) require immediate stabilization of the airway. Initially stable PNI patients may still require airway protection based on the projected course of their injury or evidence of deterioration. Signs that strongly suggest the need to secure the airway urgently include (see 'Airway management' above):

•Significant bleeding or hematoma

•Hemoptysis

•Subcutaneous emphysema

•Bruit or thrill

•Neurologic deficit

•Distorted neck anatomy

•Stridor

•Difficulty or pain when swallowing secretions

•Abnormal voice, especially hoarseness ("hot potato voice")

In most cases of PNI, rapid sequence intubation (RSI) can be used to establish an airway when necessary (algorithm 2). An "awake" technique may be prudent prior to administering a neuromuscular blocking agent. Intubation should be performed under direct laryngoscopic or endoscopic visualization. Be ready for unexpected difficulty; prepare simultaneously for tracheal intubation, non-surgical rescue device (eg, an extraglottic device), and surgical airway management (ie, triple setup).

●Clinical features – Careful physical examination identifies most arterial wounds but can miss important esophageal and venous injuries (table 2). Examine for soft and hard signs of significant injury (table 1). (See 'General hard and soft signs' above.)

•Laryngotracheal injuries – These can result in respiratory distress, stridor, subcutaneous air, hemoptysis, odynophagia, dysphonia, or anterior neck tenderness. (See 'Laryngotracheal injuries' above.)

•Vascular injury – Signs include significant bleeding or hematoma, decreased or absent peripheral pulses, global or focal neurologic deficits (eg, stroke), and bruits or thrills. Intact pulses do not rule out vascular injury. (See 'Vascular injuries' above.)

•Pharyngoesophageal injuries – These are uncommon and often occult but are associated with high morbidity and mortality. Suggestive signs include dysphagia, blood in the saliva, hematemesis, and subcutaneous air. (See 'Pharyngoesophageal injuries' above.)

•Nervous system injuries – These can involve the central nervous system (spinal cord) or the peripheral nervous system (cranial nerves VII though XII, sympathetic chain, peripheral nerve roots, brachial plexus). (See 'Nervous system injuries' above.)

●Diagnostic approach of stable patient – Although many trauma specialists advocate using multidetector computed tomography with angiography (MDCT-A) for the evaluation of stable patients with PNI, no consensus exists as to the best diagnostic approach. We agree that imaging with MDCT-A is an important part of the workup, in combination with physical examination and a plain chest radiograph. The relative advantages and disadvantages of various approaches are discussed in the text. (See 'Diagnostic strategies for specific scenarios and injury types' above.)

Additional evaluation (eg, esophagoscopy) is necessary for any PNI that violates the platysma and is associated with soft signs of esophageal injury or when signs seen on MDCT-A suggest injury. Esophageal injuries may be missed by MDCT and cause life-threatening sequela. (See 'Pharyngoesophageal injury' above.)

●"No-zone" management – No-zone management algorithms are based on patient stability, presence of soft versus hard signs of injury, and the results of MDCT-A, regardless of injury location, which leads to selective operative management of stable patients. Controversy surrounds the indications for mandatory surgical exploration, particularly with zone II injuries. Definitive management of stable patients with PNI varies by institution and local surgical practice. (See 'Anatomic zone-based versus no-zone management' above.)

●Disposition – Stable patients require close observation in a monitored setting for serial examinations. Stable patients at nontrauma centers with concerning symptoms or signs (table 1) should be transferred to a trauma center if definitive care cannot be provided. (See 'Consultation and disposition' above.)