What is the appropriate workup for a patient with a neck gunshot wound?

Workup for Neck Gunshot Wound

Hemodynamically unstable patients or those with hard signs of vascular or aerodigestive injury require immediate surgical exploration without any imaging—proceed directly to the operating room. 1, 2

Initial Assessment: Hard Signs vs. Soft Signs

The workup is determined by clinical presentation, not anatomic zone. 1, 2

Hard Signs (Immediate Surgical Exploration Required):

• Active hemorrhage or pulsatile hematoma 2
• Expanding hematoma 2
• Hemodynamic instability 2
• Airway compromise or air bubbling from wound 2
• Hemoptysis 2
• Massive hematemesis 2
• Bruit or thrill over vessels 2
• Unilateral upper-extremity pulse deficit 2

If any hard signs are present, transfer immediately to the operating room—delaying surgical exploration significantly increases mortality. 1, 2 All patients with gunshot wounds arriving in hemorrhagic shock require rapid transfer to the operating room for surgical bleeding control. 1

Soft Signs (Imaging-Guided Management):

• Nonpulsatile/nonexpanding hematoma 2
• Dysphonia 2
• Dysphagia 2
• Subcutaneous emphysema 2
• Venous oozing 2

Imaging Protocol for Hemodynamically Stable Patients Without Hard Signs

Primary Imaging:

CT angiography (CTA) is the first-line imaging modality for all hemodynamically stable patients without hard signs, regardless of injury zone. 3, 1, 4

• CTA has 90-100% sensitivity and 98.6-100% specificity for detecting vascular injuries 3, 1
• CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 3, 1
• Perform CT esophagography in conjunction with CTA for suspected digestive tract injuries (sensitivity 95-100%) 1

Plain Radiography:

• Obtain neck radiographs to identify radio-opaque foreign bodies, soft-tissue swelling, airway competency, fractures, and subcutaneous emphysema 3
• This is typically followed by CTA unless hard signs necessitate immediate surgery 3

Problem-Solving Imaging:

• Catheter angiography: Reserved for equivocal CTA with concerning foreign body trajectory or when endovascular therapy is planned 3, 1
• Digital subtraction angiography may be more sensitive when metallic foreign bodies cause streak artifact on CTA 3

Airway Management

Secure the airway early in the emergency department if there is any concern for airway compromise—35% of patients with facial/neck gunshot wounds require urgent airway control, though only a minority need surgical airway. 5

• Assess for laryngeal fracture or cricotracheal separation, which can be rapidly fatal 6
• Timely airway stabilization is critical when high suspicion for cricotracheal separation exists based on mechanism 6

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg in patients with suspected spinal cord injury to reduce mortality 1
• Initiate massive transfusion protocol as needed for ongoing hemorrhage 1

Additional Diagnostic Considerations

Neurologic Assessment:

• Suspect and assess spinal cord injury clinically and with CT 7
• Obtain head CT even in awake and alert patients if trajectory suggests intracranial injury (across base of skull)—serious intracranial pathology was found in 9 of 14 awake patients in one series 5
• MRI is valuable for evaluating spinal cord injury, traumatic disk injury, and ligamentous injury in stable patients 4

Vascular Evaluation:

• Emergency angiography may identify vascular injuries requiring therapy by neck exploration or embolization 5

Multidisciplinary Coordination

Early subspecialty involvement is essential given complex anatomy and potential for multiple system injuries. 1

• Involve otolaryngology, vascular surgery, neurosurgery, and plastic surgery early 1
• 44% of patients ultimately require surgical treatment and 25% develop complications 5

Common Pitfalls

• Do not delay surgical exploration for imaging in patients with hard signs—mortality increases significantly with delays 1, 2
• Do not rely on anatomic zones alone—the "no-zone" approach focusing on clinical signs is recommended 1, 2
• Do not assume awake/alert patients lack serious injury—intracranial pathology can be present despite normal mental status 5
• Do not underestimate airway needs—secure early even if initially stable 5, 6