The most important part of the evaluation is a careful and thorough physical examination. Obtain essential information about the mechanism of injury, is vital. This should include responses the following considerations:

When: Timing of the injury

Where: Location of both the injury and number of wound sites (suspected entry and exit wounds), as well as their nearness to vital structures.

How: The type of wounding agent used, such as a knife, handgun, etc.

Events surrounding the timing of the injury: This information can be obtained from the emergency management report and the law enforcement report.

Any other existing or underlying medical condition(s).

It is important to determine the extent of the injury and identify any associated injuries. Beware that are uncommonly isolated injuries, particularly in cases involving blunt trauma. Always attempt to identify any associated injuries.

Evaluate the neck for hemorrhage, hematoma, ecchymosis, edema, or any anatomic distortion. Auscultate for carotid bruits, stridor. Examine the neck for any tenderness or subcutaneous emphysema. The presence of certain findings provides clues for clinically significant vascular and aerodigestive injuries. Beware that signs and symptoms may be delayed. Bubbling or air emanating from a wound may suggest a tracheal injury. Crepitus may indicate that air has moved into the soft tissue space and should suggest prompt evaluation for injury to the trachea, esophagus, or pulmonary tree. A careful evaluation of the wound to determine the extent of the injury is required. Assess for penetration of the platysma. However, wounds should never be probed blindly, as this may cause uncontrolled bleeding. A full neurologic examination should also be performed.

Evaluation of neck injuries warrants notification of a trauma team or surgeon if either is available. Since physical examination may not be reliable in ruling out injuries in patients with neck trauma, one should consider a low threshold for obtaining additional imaging studies and/or a surgical consultation. Periodic examination is required to identify deterioration in clinical status as well as any ongoing. The value of a thorough secondary survey to evaluate for additional injuries cannot be over-emphasized in such patients. Diagnostic testing is performed for stable patients manifesting soft signs of injury and, sometimes even for those who are asymptomatic at initial presentation. [8][9]

Chest Radiography

Obtain anterior and lateral neck and chest radiographs in any patient presenting with significant neck trauma and look for hemothorax, pneumothorax, or pneumomediastinum. These should be obtained especially for patients with zone 1.

Angiography

Angiography is the initial study to evaluate for vascular injury. This may provide information about injuries to additional structures and may delineate the path of the projectile. Since it is less invasive, it is more commonly used to define vascular neck injury.

Conventional Angiography

A four-vessel angiography with venous-phase imaging has a sensitivity of greater than 99%. This is the “gold standard” for evaluating the vascular injury. If performed, should include the carotid and vertebral vessels, the intracranial portion of the carotid artery in zone 3 injuries, and the aortic arch with its branches in zone 1 injuries.

Duplex Ultrasonography

Duplex ultrasonography can be obtained in stable patients. It is noninvasive and relatively inexpensive, but it is operator dependent.  In addition, non-occlusive injuries may be missed if the flow is preserved, such as with intimal flaps and pseudoaneurysms. Its role in zone III evaluation is also limited.

Esophagography 

Esophagography should be performed if an esophageal perforation is suspected.

Since the neck houses vital structures, prompt evaluation, and rapid intervention are required. The initial assessment should be performed according to the ATLS protocols. An immediate trauma service consultation should be obtained for patients with suspicion of vascular, tracheal, or esophageal injury.[10][11][12]

Priorities in the management of patients with neck trauma are like those for any other patient with a life-threatening condition.  The primary priorities are securing the airway, maintaining ventilation, controlling hemorrhage, and treating shock.  At the same time, check vital signs and determine the stability of the patient. Patients with neck may have other life-threatening injuries that may take precedence.

Airway: As always, the priority is airway stabilization, particularly in patients with neck trauma, while maintaining cervical spine immobilization. Remember that in-line stabilization should always be maintained when there is a concern for a cervical spine injury. Up to 10% of patients with penetrating neck injuries may present with airway compromise. Be aware that despite a stable initial appearance, airway compromise can ensue rapidly.

Beware that swelling, distorted anatomy, and hematoma formation may contribute to impending airway obstruction in facial or neck trauma. Therefore, early airway control should be considered as the conditions may rapidly worsen.

Breathing: Evaluate the breathing and assess for any hemothorax or pneumothorax, particularly with penetrating zone 1 injuries

Circulation: Direct, simple pressure on the open wounds should be used to control bleeding in the emergency department. Wounds that have air sucking or bubbling should be covered with Vaseline gauze. No blind probing of the wound and no clamping of the vessels should occur in the emergency department. It is important not to occlude both carotid arteries or obstruct the patient's airway. Avoid nasogastric tube placement in patients with penetrating neck injury because of the risk of hematoma rupture. The agitation of the patient during tube insertion may precipitate bleeding.

Further management of the patient with penetrating neck trauma depends on the anatomic zone of injury, clinical presentation, and hemodynamic stability. Determine the zone of injury, as this will determine evaluation and management strategy.

Zone 1: Since up to one-third of patients with a clinically significant zone 1 injury may have no symptoms at their initial presentation, many centers advocate vascular evaluation of the aortic arch and great vessels, with an esophageal evaluation.

Zone 2: This area has easier surgical access and poses a low risk for adverse sequelae from exploration. The decision for surgical exploration depends on the symptoms.

Symptomatic penetrating zone 2 injuries should undergo neck exploration.

Asymptomatic patients with penetrating zone 2 injuries may be treated with either mandatory exploration or directed evaluation and serial examinations.

Indications for an angiogram: a stable patient with persistent hemorrhage or neurologic deficits. The presence of Horner syndrome (sympathetic nerve plexus injury) and hoarseness (recurrent laryngeal nerve injury). This suggests a violation of carotid sheath.

Zone 3

In this zone, there is potential for injury to major blood vessels and the cranial nerves close to the skull base. Beware that patients with arterial injuries may be asymptomatic at their initial presentation, and surgical exposure and control of bleeding in this location may be quite difficult.  In addition, many vascular injuries are amenable to definitive treatment by an interventional radiologist. Therefore, the injury can be potentially treated in the same setting like the one in which the diagnostic angiogram is done.

Bottom Line

1. Zones 1 and 3:  Difficult access, and exposure, vascular control may be challenging
2. No mandatory exploration, however, angiography is suggested.

For Unstable Patients

All unstable patients with evidence of vascular or aero-digestive injury should receive further evaluation by performing an invasive intervention. These patients should be transferred to the operating room for definitive care depending on the type and location of injury as well as associated injuries.

For Stable Patients

1. Whether to perform mandatory exploration of all zone 2 injuries
2. Whether to obtain invasive intervention.in all zone 1 and 3 injuries

With improvements in multidetector  (angiography, “mandatory” neck exploration for platysma violation and “mandatory” arteriography for zones 1 and 3 injuries are falling out of favor. It is important that all patients with platysma muscle violation be admitted to the surgical service or the observation unit for ongoing observation, regardless of their stability.

Blunt Trauma

Up to 5% of traumatic injuries to the neck are due to blunt trauma. Motor vehicle accidents are the most frequent cause. It occurs when an unrestrained passenger may strike the neck on a dashboard or steering wheel.

Blunt trauma can damage the vessels by the following mechanisms

1. Direct damage
2. Excessive rotation and/or hyperextension: This causes stretching of the arteries and veins resulting in a shear injury.

It is often associated with other significant injuries. Beware that there are uncommonly isolated injuries, particularly in blunt trauma; therefore, always identify any associated injuries. 

• Injury to the spinal cord
• Strangulation

• Airway obstruction
• Aspiration
• Vocal cord paralysis
• Perforated esophagus
• Severe vascular injury
• Necrotizing infection
• Stroke
• Air embolism
• Pneumothorax, hemothorax

In general, all trauma is managed by an interprofessional team of specialists that also includes nurses, physical therapists, dietitians, social workers, and occupational therapists. Those sustaining neck injuries associated with neurological deficits often require prolonged treatment that may extend for months. Thus, a visiting nurse is ideal to follow up on these patients. For those who have difficulty swallowing because of injury to the esophagus, one may even require a temporary feeding tube. In addition, those with a tracheostomy often require a home care nurse until they are weaned off the tracheal tube.  Only through an interprofessional care can the outcomes be improved and the quality of life of these patients be improved.[13][14][2]

Outcomes

Overall, injuries to zone 1 have the highest morbidity and mortality. Zone ll injuries are the most common after penetrating trauma, but because they can be readily accessible, they also have the best prognosis. Injuries to Zone ll can be challenging because access to some structures may not be easy. The prognosis of these injuries is guarded. In individuals who suffer complete transection of the spinal cord, the injury is almost always fatal. Individuals who do retain neurological function including preservation of rectal tone, usually have a good outcome. However, if the neurological deficits persist, the outcomes are poor. When the vasculature structures are injured by blunt trauma, the outcomes are worse compared to penetrating injuries. In many neck injuries, one also has to search for airway and esophageal injuries as they may not always be apparent. Overall, the mortality rate for patients suffering penetrating trauma to the neck varies from 2-5%, but if a major blood vessel has ruptured, this is often fatal in about 70% of cases.[15] (Level V)