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Penetrating neck injuries: Initial evaluation and management

Kim Newton, MD
Section Editors
Maria E Moreira, MD
Richard G Bachur, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Penetrating neck injuries (PNIs) refer to neck injuries resulting from gunshot wounds, stab wounds, or penetrating debris, such as glass or shrapnel, that penetrate the platysma. PNI can cause injuries to the aerodigestive and neurovascular systems.

Before World War II, all PNIs were treated expectantly ("watch and wait"), resulting in mortality rates as high as 35 percent [1]. In an attempt to reduce the unacceptably high death rates associated with PNIs, a mandatory surgical approach was adopted. Exploratory surgery was performed in all patients with PNI regardless of signs and symptoms or patient stability or the location of injury. This approach reduced mortality rates substantially [2]. Mandatory surgical exploration of PNIs remained widely accepted well into the 1990s, when it became clear that despite improved outcomes, mandatory surgery led to unacceptably high negative exploration rates (in one large series, 58 percent of patients had sustained no major injury) [3].

The high negative surgery rate led to the development of a zone-based, selective surgical approach to stable patients with PNI. This new approach offered the emergency physician and surgeon, a spectrum of diagnostic and therapeutic approaches based on what part of the neck was injured (figure 1) and the status of the patient. The rationale behind a zone-driven selective surgical approach was based in part on the relative ease with which surgeons could access Zone II (mid-neck) injuries compared with the more technically challenging Zone II and III injuries. Much debate followed as to the best approach for symptomatic, stable patients [1,4,5]. One persistent controversy was whether all Zone II PNIs required surgical exploration or whether selected patients could be managed nonoperatively.

During the 1990s and early 2000s, most research and many trauma surgeons favored some form of selective management. One early review concluded that Zone II injuries had similar outcomes regardless of whether mandatory surgery or selective management was pursued, while subsequent research supported a selective approach [4,6-9]. Practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) concluded that both approaches were justifiable and safe [10].

In part due to advances in diagnostic imaging, a "no-zone" management strategy has been developed [11]. Using this approach, patients are categorized as unstable or stable, rather than according to the zone of the neck injury, with unstable patients transferred rapidly to the operating room. Those who are stable but symptomatic undergo multidetector computed tomography angiography (MDCT-A), the results of which, in combination with examination findings, help to determine whether further diagnostic tests are performed or surgical intervention is needed.


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Literature review current through: Sep 2016. | This topic last updated: Jun 16, 2016.
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