What's the next step for a patient with a zone 2 neck injury, who is vitally stable, with no signs of vascular or aerodigestive injuries, and no symptoms of hoarseness or subcutaneous emphysema?

Management of Zone 2 Neck Injury in a Stable Patient

For a patient with a zone 2 neck injury who is vitally stable with no signs of vascular or aerodigestive injuries and no hoarseness or subcutaneous emphysema, CT angiography (CTA) of the neck is the recommended next step. 1, 2

Rationale for CTA

• CTA has replaced conventional angiography as the first-line imaging modality for evaluating penetrating neck injuries in hemodynamically stable patients
• High diagnostic accuracy:
  • Sensitivity: 90-100% for vascular injuries
  • Specificity: 98.6-100% for vascular injuries 1
  • Simultaneously evaluates extravascular soft tissues and aerodigestive structures with 100% sensitivity and 93.5-97.5% specificity 2

Clinical Decision-Making Algorithm

1. Initial assessment: Patient already determined to be vitally stable with no hard signs of injury

   • No active hemorrhage, pulsatile/expanding hematoma, or airway compromise
   • No hoarseness or subcutaneous emphysema (soft signs)

2. Imaging recommendation: CTA of the neck

   • Even in the absence of soft signs, CTA is indicated to evaluate the trajectory of the penetrating agent and identify potential occult injuries 1, 2
   • This approach has been shown to decrease overall neck explorations and negative neck explorations 1

3. Post-CTA management:

   • If CTA negative: Observation may be appropriate
   • If CTA positive for vascular injury: Consider angiography or surgical exploration based on severity
   • If CTA positive for aerodigestive injury: Proceed with contrast esophagram (barium swallow) 2

Important Considerations

• While the "no zone" approach (using physical examination to guide imaging) has gained popularity, Zone 2 injuries still require thorough evaluation as occult injuries may be present 3, 4
• CTA provides valuable additional information about cervical soft tissues, aerodigestive tract, and potential spinal injuries in a single examination 5
• If there is high risk for contrast reaction, premedication according to ACR recommendations should be considered; if contrast cannot be administered, unenhanced CT may be performed with understanding that vascular evaluation will be limited 1

Pitfalls to Avoid

• Relying solely on physical examination without imaging can miss occult injuries, especially in Zone 1 and Zone 3 injuries 4
• CTA may be limited by artifacts from metallic fragments, in which case conventional angiography may be necessary 5
• Negative CTA with persistent clinical suspicion for esophageal injury should prompt additional diagnostic tests like contrast esophagram 2

By following this evidence-based approach with CTA as the next step, you can effectively identify or exclude vascular and aerodigestive injuries in this stable patient with a zone 2 neck injury, potentially avoiding unnecessary surgical exploration.