What is the management of a neck gunshot wound?

Management of Neck Gunshot Wounds

Patients with neck gunshot wounds presenting with hard signs of vascular or aerodigestive injury require immediate surgical exploration without imaging, while hemodynamically stable patients without hard signs should undergo CT angiography first to guide selective management. 1, 2

Initial Stabilization and Airway Management

Airway control is the first priority and must be secured early, as 35% of patients with penetrating facial/neck trauma require urgent airway intervention in the emergency department. 3

• Perform rapid sequence induction with direct laryngoscopy and gum elastic bougie if intubation is needed 2
• Use manual in-line stabilization with removal of the anterior cervical collar during intubation if cervical spine injury is suspected 2
• Avoid Sellick maneuver in patients with suspected cervical spine injury 2
• Consider early intubation before progressive facial edema from vascular injuries makes airway management impossible 4
• Only 2% of patients require surgical airway despite high rates of airway intervention 3

Hemodynamic Resuscitation

Maintain systolic blood pressure >110 mmHg in patients with suspected spinal cord injury to reduce mortality. 2

• Patients with gunshot wounds presenting in hemorrhagic shock require immediate transfer to the operating room for surgical bleeding control 5
• Delaying surgical exploration in patients with hard signs significantly increases mortality 1
• Initiate massive transfusion protocol as needed for ongoing hemorrhage 5

Clinical Assessment: Hard Signs vs Soft Signs

The presence of hard signs mandates immediate surgical exploration without imaging, while soft signs allow time for diagnostic workup. 1, 2

Hard Signs Requiring Immediate Exploration:

• Active hemorrhage or pulsatile hematoma 1
• Expanding hematoma (indicates active bleeding threatening airway or causing exsanguination) 1
• Hemodynamic instability 1
• Bruit or thrill over vessels 1
• Unilateral upper-extremity pulse deficit 1
• Airway compromise 1
• Hemoptysis (suggests tracheal or major vascular injury) 1
• Massive hematemesis 1
• Air bubbling from the wound 1
• Pneumothorax (indicates aerodigestive tract injury) 1
• Dysphonia (suggests laryngeal or recurrent laryngeal nerve injury) 1
• Massive subcutaneous emphysema 2

Soft Signs Requiring Further Evaluation:

• Dysphagia (may indicate esophageal or pharyngeal injury) 1
• Nonpulsatile/nonexpanding hematoma 1
• Venous oozing 1
• Minor subcutaneous emphysema 2

Imaging Protocol for Stable Patients

CT angiography (CTA) is the first-line imaging modality for hemodynamically stable patients without hard signs, regardless of injury zone. 1, 2

• CTA has 90-100% sensitivity and 98.6-100% specificity for detecting vascular injuries 1, 2
• CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 2
• Perform CT esophagography in conjunction with CTA for suspected digestive tract injuries (sensitivity 95-100%) 2
• Initial plain radiographs may identify radio-opaque foreign bodies, soft-tissue swelling, airway compromise, fractures, and subcutaneous emphysema before CTA 2
• Reserve catheter angiography for equivocal CTA findings with concerning foreign body trajectory 2
• Emergency angiography identified vascular injuries in 51% of patients when performed (19 of 37 patients), with 11 requiring therapeutic intervention 3

Zone-Based Considerations

The American College of Radiology recommends a "no-zone" approach focusing on clinical signs rather than anatomic zones alone. 1, 6

• Zone I (clavicles to cricoid): Most challenging surgical access due to thoracic inlet bony constraints 6
• Zone II (cricoid to mandibular angle): Historically most accessible for exploration, but selective management now preferred 6, 7
• Zone III (mandibular angle to skull base): Difficult surgical access 6
• Clinical signs, not anatomic zone, determine need for immediate exploration 1, 6

Surgical Management

Proceed directly to neck exploration for patients with hard signs. 1

• All 41 patients with gunshot wounds arriving in hemorrhagic shock required rapid transfer to operating room 5
• Vascular injuries may require direct repair, autologous vein grafting, or embolization 3, 4
• 44% of patients with facial/neck gunshot wounds ultimately required surgical treatment 3
• Surgical decompression is indicated for spinal cord injury with deteriorating or stable neurologic status and cord compression by bullet or bone fragments 7

Additional Diagnostic Considerations

Suspect intracranial injury when trajectory crosses the skull base, even in awake and alert patients. 3

• Head CT demonstrated serious intracranial pathology in 9 of 14 awake and alert patients with trajectories suggesting intracranial injury 3
• MRI is valuable for evaluating spinal cord injury, traumatic disk injury, and ligamentous injury in stable patients without metallic foreign bodies 2
• Assess for cervical spine injury clinically and with imaging; maintain spine immobilization until cleared 2, 7

Multidisciplinary Coordination

Early subspecialty involvement is essential given the complex anatomy and potential for multiple system injuries. 3, 8

• Involve otolaryngology for aerodigestive injuries 8
• Involve vascular surgery for major vessel injuries 3
• Involve neurosurgery for intracranial or spinal cord injuries 7, 3
• Involve plastic surgery for complex soft tissue reconstruction 8

Common Pitfalls

• Never delay surgical exploration in patients with hard signs - mortality increases significantly with delays 1
• Do not rely on physical examination alone in stable patients without appropriate imaging 2
• Do not fail to consider intracranial injury when cervical vascular injury is present 2
• Do not miss vertebral artery pseudoaneurysm - one patient died 4 months after injury from this missed diagnosis 9
• Anticipate progressive facial edema from arteriovenous fistulas that can make delayed airway management impossible 4