eMedicine Specialties > Trauma > Head and Neck Trauma

Penetrating Neck Trauma: Follow-up

Author: Daniel Mark Alterman, MD, RN, Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine
Coauthor(s): Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine; Eugene Y Cheng, MD, FCCM, Consulting Staff, Department of Anesthesiology, The Permanente Medical Group; Val Selivanov, MD, Consulting Staff, Administrative Chief, Department of Surgery, Kaiser Permanente of Santa Teresa
Contributor Information and Disclosures

Updated: Nov 19, 2009

Outcome and Prognosis

Vascular trauma is present in 25% of penetrating neck injuries, with mortality rates approaching 50% in some studies. Tracheobronchial injuries may have an incidence of less than 10% to as high as 20% and a mortality rate of as high as 20%. The injured cervical esophagus can result in devastating complications and eventual outcomes, such as leakage of saliva, bacteria, refluxed acid, pepsin, and even bile. Undiagnosed, this can produce early suppurative infection and an intense necrotizing inflammatory response in the neck, as well as a more devastating outcome if it descends to the mediastinum. An 11-17% increase in the overall mortality rate has been observed after delays of 12 hours in the diagnosis of esophageal injuries.

Future and Controversies

The definitive management of penetrating neck trauma continues to be under debate and investigation. Among these investigations is the question of whether the mechanism of injury should dictate the specific management approach. For example, the question exists as to whether a different approach should be applied to gunshot injuries compared to stab wounds.

Although the debate between mandatory neck exploration and selective management already may have favored the latter, the debate has not been resolved with finality. Currently, the debate focuses on selective management versus expectant management and whether the paradigm has shifted too far.

Specific to the ongoing management debate is the question of which essential diagnostic modalities are required for optimal evaluation in the selective management approach. The question exists as to which diagnostic modalities ensure that injuries are not missed.

The optimal surgical management of the carotid artery injury is another controversy in need of resolution. The issues involve whether severe neurologic deficits (ie, coma) and demonstrated absence of antegrade flow in the internal carotid artery contraindicate repair. In several studies, the reestablishment of antegrade flow in these cases has been suggested to be hazardous because it may convert an ischemic infarction into a hemorrhagic infarction.

Further controversy exists regarding the optimal management of vascular injuries identified solely on screening CT angiography in the absence of clinical signs of vessel injury. However, most of these discussions arise in the setting of blunt neck injury. The use of these rapidly developing endovascular techniques for the treatment of subclinical injuries in the neck lacks clear guidelines at present.

 


More on Penetrating Neck Trauma

Overview: Penetrating Neck Trauma
Workup: Penetrating Neck Trauma
Treatment: Penetrating Neck Trauma
Follow-up: Penetrating Neck Trauma
Multimedia: Penetrating Neck Trauma
References
Further Reading
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References

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Further Reading

Related eMedicine Topics

Clinical Guidelines

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Keywords

penetrating neck trauma, penetrating neck injury, neck trauma, traumatic neck injury, neck injury, blunt neck trauma, blunt neck injury, penetrating neck wounds, gunshot wounds, stab wounds, puncture wounds, impalement injuries

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Contributor Information and Disclosures

Author

Daniel Mark Alterman, MD, RN, Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine
Daniel Mark Alterman, MD, RN is a member of the following medical societies: American College of Surgeons and International College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Eugene Y Cheng, MD, FCCM, Consulting Staff, Department of Anesthesiology, The Permanente Medical Group
Eugene Y Cheng, MD, FCCM is a member of the following medical societies: American College of Physicians, American Society of Anesthesiologists, International Anesthesia Research Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Val Selivanov, MD, Consulting Staff, Administrative Chief, Department of Surgery, Kaiser Permanente of Santa Teresa
Val Selivanov, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine
Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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