Management of Trauma Neck Lacerations
For penetrating neck trauma, immediately assess for hard signs of injury (active hemorrhage, expanding hematoma, airway compromise, hemoptysis, air bubbling in wound) which mandate direct surgical exploration without imaging, while stable patients with soft signs should undergo CT angiography first to guide selective management. 1, 2
Initial Stabilization and Assessment
Immediate Life-Threatening Interventions
- Apply direct local compression to control active bleeding from open neck wounds as the first-line hemorrhage control measure 3
- Place an occlusive dressing over neck wounds and apply direct pressure, but never apply circumferential wrapped bandages around the neck as this can compromise the airway 3
- For penetrating wounds with persistent bleeding, consider Foley catheter insertion directly into the wound tract to achieve tamponade through balloon inflation 3
- Stabilize any impaled objects with bulky dressings and only remove if obstructing the airway 3
Airway Management Priority
- Perform endotracheal intubation without delay if airway obstruction, altered consciousness (GCS ≤8), hypoventilation, or hypoxaemia are present 3
- For patients requiring intubation with suspected cervical spine injury, use manual in-line stabilization with removal of the anterior cervical collar during intubation 2
- Consider rapid sequence induction with videolaryngoscopy rather than awake fiberoptic intubation in time-critical situations, as videolaryngoscopy has become the preferred approach over historical awake techniques 3
- Maintain cervical spine immobilization throughout initial assessment for any patient with suspected spinal cord injury 2
Hemodynamic Resuscitation
- Establish IV access and administer crystalloid fluids to maintain systolic blood pressure >90 mmHg in hemorrhagic shock 1
- For patients with suspected spinal cord injury, target systolic blood pressure >110 mmHg to reduce mortality 2
- Avoid hypoxaemia (Grade 1A recommendation) and maintain normoventilation 3
Clinical Decision Algorithm Based on Hard vs Soft Signs
Hard Signs Requiring Immediate Surgical Exploration (No Imaging)
Proceed directly to the operating room without any imaging studies if any of the following are present 1, 2:
- Active hemorrhage or pulsatile/expanding hematoma 1
- Hemodynamic instability 1
- Airway compromise or air bubbling from the wound 1
- Hemoptysis or massive hematemesis 1
- Dysphonia (suggests laryngeal/recurrent laryngeal nerve injury) 1
- Pneumothorax 1
- Unilateral upper-extremity pulse deficit 1
- Bruit or thrill over the wound 1
Critical pitfall: Delaying surgical exploration in patients with hard signs significantly increases mortality 1, 2
Soft Signs Requiring Imaging Before Decision
Obtain CT angiography (CTA) as first-line imaging if the patient is hemodynamically stable with only soft signs 1, 2:
- Nonpulsatile or nonexpanding hematoma 1
- Venous oozing 1
- Subcutaneous emphysema (minor) 2
- Dysphagia 1
- Dysphonia (mild) 1
Imaging Protocol for Stable Patients
CT Angiography as Gold Standard
- CTA is the first-line imaging modality with sensitivity of 90-100% and specificity of 98.6-100% for detecting vascular injuries 2, 3
- CTA simultaneously evaluates extravascular soft tissue and aerodigestive injuries with 100% sensitivity and 93.5-97.5% specificity 2
- The American College of Radiology recommends a "no-zone" approach focusing on clinical signs rather than anatomic zones alone 1, 4
Additional Imaging Based on CTA Findings
- Obtain CT esophagography or water-soluble contrast swallow if esophageal injury is suspected (sensitivity 95-100%) 2
- Reserve catheter angiography for equivocal CTA findings or when endovascular intervention is planned 3, 2
- Consider plain radiographs initially to identify radio-opaque foreign bodies, soft-tissue swelling, airway patency, fractures, and subcutaneous emphysema before CTA 2, 3
Limited Role Modalities
- Ultrasound has limited utility due to overlying soft tissue injury, cervical collars, and inability to evaluate deep structures or Zone I/III injuries 3, 2
- MRI/MRA are valuable for evaluating spinal cord injury, disk injury, and ligamentous injury in stable patients without metallic foreign bodies, but impractical in acute trauma 3, 2
Zone-Based Anatomic Considerations
While the modern approach prioritizes clinical signs over zones, understanding anatomy remains important 4:
- Zone I (clavicles to cricoid): Most challenging surgical access due to thoracic inlet constraints 4
- Zone II (cricoid to mandibular angle): Most accessible for surgical exploration, contains carotid arteries and jugular veins 4
- Zone III (mandibular angle to skull base): Difficult surgical access 4
However, the presence of hard signs determines need for immediate exploration regardless of zone 1, 4
Surgical Management Principles
Operative Indications
- All wounds penetrating deep to the platysma warrant surgical exploration if hard signs are present 1
- 74% of hemodynamically stable patients with hard signs who received CTA were able to avoid surgical neck exploration through selective management 3
Wound Management Specifics
- Control scalp bleeding with direct pressure 3
- Avoid uncontrolled clamping of vessels as this can damage adjacent nerves 5
- Injuries to the airway demand immediate reconstruction to prevent permanent damage 5
Common Pitfalls to Avoid
- Never delay surgical exploration in patients with hard signs to obtain imaging—mortality increases significantly with delays 1, 2
- Never apply circumferential neck bandages as they can compromise the airway 3
- Never rely solely on physical examination without appropriate imaging in stable patients with soft signs 2
- Do not fail to maintain cervical spine immobilization during initial assessment and airway management 2
- Consider potential brain injury when cervical vascular injury is identified, as end-organ damage may require additional imaging 3, 2