What is the management for neck lacerations?

Management of Neck Lacerations

Neck lacerations require immediate surgical exploration if there is an expanding hematoma, active hemorrhage, or hemodynamic instability, while stable patients without hard signs should undergo CT angiography regardless of injury zone. 1

Initial Assessment

• Perform rapid evaluation of airway, breathing, and circulation

• Assess for "hard signs" of vascular or aerodigestive injury:

  • Active hemorrhage
  • Expanding hematoma
  • Airway compromise
  • Hemodynamic instability
  • Subcutaneous emphysema/crepitus

• Establish large-bore IV access for potential fluid resuscitation 1

• Collect baseline labs including CBC, coagulation studies, and cross-match 1

Airway Management

• If signs of airway compromise exist, secure airway immediately
• Important caution: Multiple intubation attempts can worsen laryngeal edema 1
• Consider opening the wound and evacuating hematoma before intubation attempts 1
• Have emergency front-of-neck airway equipment immediately available (scalpel, bougie, cuffed tube) 1

Management Algorithm

For Unstable Patients (Hard Signs Present):

1. Immediate surgical exploration is mandatory 1, 2
2. Apply direct pressure to control active hemorrhage 1
3. Prepare for possible blood transfusion 1
4. Surgical approach depends on injury location:
   • Left-sided anterolateral thoracotomy for lower neck injuries (zone 1)
   • Consider clamshell approach for better exposure if needed 3
   • Injuries below cricoid cartilage may require midline sternotomy with cervicotomy 1

For Stable Patients (No Hard Signs):

1. CT angiography (CTA) of the neck is first-line imaging 1, 2
   • High sensitivity (90-100%) and specificity (98.6-100%) for vascular injuries
   • Excellent for evaluating extravascular soft tissues and aerodigestive structures
2. If CTA shows vascular injury:
   • Consider angiography or surgical exploration based on severity 1
3. If aerodigestive injury suspected:
   • Proceed with contrast esophagram (barium swallow) 1

Antibiotic Administration

• Start antibiotics immediately (within 3 hours of injury) 1
• First-generation cephalosporin (e.g., cefazolin) for clean wounds
• Add aminoglycoside coverage for contaminated wounds 1
• Continue antibiotics for 48-72 hours 1

Surgical Considerations

• Surgical exploration indicated for:

  • Active hemorrhage
  • Expanding hematoma
  • Suspected vascular injury
  • Significant soft tissue damage
  • Joint involvement 1

• For tracheal/bronchial injuries:

  • Small ruptures may be managed conservatively
  • Large ruptures require surgical repair 3
  • Ensure adequate exposure of injury site 3

Special Considerations

• Pediatric patients: Same principles apply but surgical approach may need modification based on anatomy 1, 4
• Elderly patients: Higher risk for complications; sensitivity of clinical criteria for detecting cervical spine injury declines significantly in patients ≥65 years 1
• Monitor for delayed complications including spinal infarction 1
• Be aware that the "no zonal approach" (based on clinical findings rather than anatomical zones) has shown superior outcomes compared to traditional zonal management 2

Potential Pitfalls

• Delaying antibiotics beyond 3 hours significantly increases infection risk 1
• Monitor for coagulopathy with significant hemorrhage 1
• Avoid excessive fluid administration that might increase bleeding 1
• Be vigilant for injuries at noncontiguous spine levels (occurs in ~20% of trauma patients) 1

The evidence strongly supports a selective approach to neck trauma based on clinical findings rather than relying solely on anatomical zones, with immediate surgical exploration for unstable patients and advanced imaging for stable patients without hard signs of injury 1, 2.