From the Guidelines
Exploration of a zone 2 neck injury is recommended for patients with hard signs of vascular or aerodigestive tract injury, as immediate surgical intervention is necessary to prevent potential life-threatening complications. These hard signs include active bleeding, expanding hematoma, bruit/thrill, pulse deficit, neurological deficit, hemoptysis, hematemesis, hoarseness, stridor, subcutaneous emphysema, or air bubbling from the wound 1. For patients with no hard signs but penetrating trauma to zone 2, selective management with imaging studies like CT angiography, esophagography, or endoscopy may be appropriate to rule out occult injuries, as supported by the ACR Appropriateness Criteria 1.
Key Considerations
- Hard signs of vascular or aerodigestive tract injury necessitate immediate surgical exploration to prevent life-threatening complications.
- Selective management with imaging studies is appropriate for patients with no hard signs but penetrating trauma to zone 2.
- CT angiography is the preferred imaging procedure to evaluate the extent of injury in patients with clinical soft injury signs or hard signs who do not require immediate surgery 1.
- Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography, have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand 1.
Rationale
The rationale for exploring zone 2 injuries with hard signs is that this area contains vital structures whose injury can lead to rapid deterioration, and direct surgical intervention allows for immediate control and repair of damaged structures. The selective approach for patients with no hard signs reduces unnecessary surgeries while maintaining safety, as supported by the evidence 1.
From the Research
Zone 2 Injury Trauma Exploration
- Zone 2 penetrating neck trauma (PNT) is typically explored when patients exhibit clinical hard signs, as recommended by the Western Trauma Association (WTA) 2.
- Clinical hard signs include airway compromise, massive subcutaneous emphysema/air bubbling through wound, expanding/pulsatile hematoma, active bleeding, shock, focal neurologic deficit, and hematemesis 2.
- The use of computed tomography angiography (CTA) in stable patients with hard signs can help decrease the rate of negative neck explorations without increasing the rate of missed injuries 2.
- Physical examination alone can also be used to evaluate and manage penetrating zone 2 neck injuries, with a low false-negative rate of 0.9% 3.
- Patients with no hard signs can be observed without imaging or surgery for a minimum of 23 hours, with a low risk of vascular injury 3.
- In cases of airway trauma, the goal is to pass the tube across the injured area without disrupting it, and a surgical airway distal to the site of injury may be the best initial approach 4.
- The choice of approach and technique for airway management depends on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment 4.