When is it safe to suture a trauma neck laceration closed?

Management of Trauma Neck Lacerations

Neck lacerations should only be sutured closed after thorough evaluation for vascular, aerodigestive, or neurological injury, with immediate surgical exploration for unstable patients and appropriate imaging for stable patients without hard signs of vascular injury.

Initial Assessment

• Evaluate for "hard signs" of vascular and aerodigestive injury requiring immediate surgical exploration: active hemorrhage, expanding hematoma, pulsatile bleeding, bruit/thrill, shock, massive subcutaneous emphysema, or air bubbling through wound 1
• Assess for "soft signs" requiring further evaluation: non-pulsatile/non-expanding hematoma, venous oozing, dysphagia, dysphonia, and subcutaneous emphysema 1
• Determine hemodynamic stability, which is the primary factor in management decision-making 2

Management Algorithm

For Unstable Patients:

• Immediate surgical exploration is required without delay for imaging studies 1, 2
• Perform damage control thoracotomy if there is massive and progressive hemorrhage (>1000 ml initial drainage or >200 ml/hr for 3+ hours) 1

For Stable Patients:

• Obtain multidetector CT angiography (CTA) for evaluation regardless of the zone of injury 1, 2
• CTA has demonstrated high sensitivity (100%) and specificity (97.5%) for detecting vascular and aerodigestive injuries 1
• Consider additional studies based on clinical suspicion:
  • Esophageal evaluation if there is concern for esophageal injury 1
  • Laryngoscopy for suspected laryngeal injury 1

When to Close Neck Lacerations

• Only close neck lacerations after thorough evaluation has ruled out significant underlying injury 1, 2
• Wounds with confirmed or suspected deep structure involvement should not be primarily closed 1
• Superficial lacerations without signs of deeper injury may be closed after proper cleaning 1, 3

Wound Closure Techniques

• Clean wounds thoroughly with sterile normal saline before closure 1
• For facial and neck wounds with minimal tension, consider:
  • Tissue adhesives for small, clean lacerations 1, 3
  • Steri-Strips for low-tension wounds 1, 4
  • Absorbable sutures for facial wounds to avoid the pain of suture removal 1
• For neck wounds specifically:
  • Use topical anesthetics (LET: lidocaine, epinephrine, tetracaine) for pain control during repair 1
  • Consider leaving wounds open if there is any concern for contamination 1

Post-Closure Care

• For facial wounds, Steri-Strips should remain in place for 5-7 days 5, 4
• For neck wounds, follow-up within 24-48 hours is recommended to assess for complications 1
• Monitor for signs of infection: increasing pain, erythema, swelling, or drainage 1

Special Considerations

• Avoid primary closure of contaminated wounds, as this increases infection risk 1
• Consider prophylactic antibiotics for contaminated wounds or wounds with high risk of infection 1
• Ensure tetanus prophylaxis is current 1
• Beware that neck wounds may appear superficial but can have significant underlying injury to vital structures 2, 6

Pitfalls to Avoid

• Never close neck wounds before ruling out injury to deeper structures 1, 2
• Avoid missing vascular injuries which can lead to delayed hemorrhage or thrombosis 1
• Don't underestimate the potential for airway compromise, which can develop hours after the initial injury 1, 6
• Avoid excessive manipulation of neck wounds before proper evaluation, as this may dislodge clots and cause hemorrhage 6