Medscape is available in 5 Language Editions – Choose your Edition here.


Penetrating Neck Trauma Workup

  • Author: Daniel Mark Alterman, RN, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
Updated: Mar 06, 2015

Laboratory Studies

See the list below:

  • Hemoglobin concentration is useful to evaluate for the immediate need for transfusion and to document the starting point for future comparison.
  • A blood specimen for typing is useful should transfusion be required. As patients who have had prior transfusions become alloimmunized, early recognition of antibody formation is essential to provide compatible blood products.
  • A toxicologic screen is indicated for the patient with an altered sensorium. This is important to help differentiate the altered sensorium of intoxication from a neurologic etiology following penetrating neck trauma with an arterial injury component.

Imaging Studies

See the list below:

  • Cervical anteroposterior and lateral radiography is used to evaluate for vertebral bony injury; retained foreign bodies; and foreign body deformity, location, size, and number.
  • Four-vessel cerebral angiography is indicated with clinical evidence of significant vascular injury (ie, hard signs) in zone I and zone III, as well as in selectively managed zone II injuries. Physical examination findings reliably guide the use of invasive testing for suspected zone II vascular injury. In fact, the percentage (about 1%) of missed vascular injuries using physical examination screening criteria is similar to the false-negative rate for angiography. Data from Ferguson and colleagues suggest that, in the absence of hard vascular signs with a zone III injury, angiography is not necessary.[7] This concept holds true for many types of suspected arterial injury. This represents a dramatic change in evaluation, as angiography was previously mandatory for all penetrating zone III injuries.
  • Hypotension and exsanguination should prompt operative exploration in most centers. Certain centers that have in-house angiographers may proceed to the angiography suite for injuries in zone I and zone III despite hypotension or hemorrhage. Angiography remains the criterion standard for defining arterial anatomy and injury complexes, with an accuracy close to 100%.
  • Arteriography demonstrates a low yield (< 1%) of findings that alter treatment in asymptomatic patients. Arteriography usually is performed using a digital subtraction angiography (DSA) technique that reduces the amount of contrast required and yields a superior computer-manipulated image for evaluation.
  • Helical computed tomographic angiography is less invasive and is showing promise in defining vascular neck injury. Possibly, in the future, this technique may replace angiography.
  • Two-dimensional Doppler studies are a noninvasive alternative to angiography to evaluate vascular injury in critical areas (principally in zone II). Its role in zone III evaluation is quite limited, given the obvious anatomic limitations of ultrasound in this region. This study typically incorporates a static B mode image of the interrogated vessel in combination with real-time ultrasound and Doppler velocity determination coupled with spectral analysis. This is covered in the umbrella term Duplex. Three-dimensional images for reformation are increasingly available but require costly imaging systems that may not be readily available in the emergency department. Such tests may be best used in stable patients with zone II injuries without any signs of vascular injury to complete the examination of the regional vital structures.
  • Esophagography is essential to evaluate for an esophageal perforation. Selecting the oral contrast medium for esophageal injury detection is controversial. One school of thought contends that oral iodinated aqueous contrast media better demonstrates perforations and anastomotic leakage with less risk of complications than barium; the sensitivity of this technique in detecting esophageal injury increases from 70-89% when combined with esophagoscopy. The other school of thought contends that aqueous contrast media is hypertonic and, if extravasated into the mediastinum, induces a local inflammatory reaction. Barium solution is inert in the mediastinum and has been used for decades within the tracheobronchial tree for contrast bronchography prior to the advent of flexible bronchoscopy.
  • Computed tomography (CT) scan is a study that can evaluate many structures at a time and that is enhanced with the use of intravenous nonionic contrast media. If available, helical or spiral CT scans permit multiplanar views and 3-dimensional reconstructions. A CT scan is excellent for helping to define and diagnose a laryngeal injury. A CT scan can also be useful to help define a missile tract. A CT scan does not increase the sensitivity of detecting an esophageal injury. If an esophageal injury is suspected, esophagoscopy is the procedure of choice.
  • CT angiography (CTA) is gaining acceptance as an adjunctive screening tool. A review by Woo and colleagues reports that the use of CTA is associated with less operative exploration, less negative explorations, and reduced use of invasive studies, such as conventional angiography.[6] Physical examination findings supplemented by CTA should have a prominent role in the selective management of penetrating neck injuries. CTA has replaced angiography as the initial study of choice in the vascular evaluation of a neck injury.[8]
  • The improved spatial resolution of the multidetector CT scan has improved the diagnostic capability and the accuracy of this modality, further supporting it as the initial study of choice for civilian injury.
  • Renewed interest as to the optimal management of wartime penetrating neck injuries has been addressed by Fox and colleagues in the delayed assessment of war casualties at Walter Reed Army Medical Center.[9] A significant number of delayed evaluations found injuries, and retained missile fragments, were a limitation to accurate assessment at the zone of injury with CT examination. They assert that, for the military injury, arteriography remains the criterion standard.
  • The advantage of magnetic resonance imaging is not elucidated clearly for penetrating neck injuries; continual evaluation and monitoring of trauma patients who are in potentially critical condition presents a problem during this procedure.
  • Even when readily available, time constraints of magnetic resonance angiogram (MRA) limit its use in the acute phase of traumatic evaluation.

Diagnostic Procedures

See the list below:

  • Direct laryngoscopy - For evaluation of oropharyngeal and tracheal injuries
  • Flexible bronchoscopy - For delineation of tracheal and bronchial injuries
  • Esophagoscopy - Flexible esophagoscopy can be used to detect an esophageal injury with less risk of procedure-related complications than rigid esophagoscopy (ie, rupture and complications from general anesthesia). Concerns exist regarding the introduction of oropharyngeal flora into the tissue planes of the neck when performing upper endoscopy in the presence of a perforation because visualization of the central lumen is aided by continuous gas insufflation through the endoscope.
Contributor Information and Disclosures

Daniel Mark Alterman, RN, MD Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine

Daniel Mark Alterman, RN, MD is a member of the following medical societies: American College of Surgeons, International College of Surgeons

Disclosure: Nothing to disclose.


Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Lewis J Kaplan, MD, FACS, FCCM, FCCP Associate Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania; Section Chief, Surgical Critical Care, Philadelphia Veterans Affairs Medical Center

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, Surgical Infection Society

Disclosure: Nothing to disclose.


Eugene Y Cheng, MD, FCCM Consulting Staff, Department of Anesthesiology, The Permanente Medical Group

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.

  1. Sarkar D, Demma A, Stulz D, Hsue G. Expect the unexpected: two cases of penetrating head and neck trauma from Operation Iraqi Freedom. Ear Nose Throat J. 2009 Sep. 88(9):E19-21. [Medline].

  2. Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury. 2009 Jul 16. epub ahead of print. [Medline].

  3. Gupta B, Gulati A, Gupta D. A rare presentation of pellet injury in the neck. ISRN Surg. 2011. 2011:306126. [Medline]. [Full Text].

  4. Dubois-Marshall S, De Kock S. Two days with a broken knife blade in the neck--an interesting case of Horner's syndrome. Emerg Med J. 2011 Jul. 28(7):629-31. [Medline].

  5. Brennan J, Lopez M, Gibbons MD, Hayes D, Faulkner J, Dorlac WC, et al. Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg. 2011 Feb. 144(2):180-5. [Medline].

  6. Woo K, Magner DP, Wilson MT, Margulies DR. CT angiography in penetrating neck trauma reduces the need for operative neck exploration. Am Surg. 2005 Sep. 71(9):754-8. [Medline].

  7. Ferguson E, Dennis JW, Vu JH, Frykberg ER. Redefining the role of arterial imaging in the management of penetrating zone 3 neck injuries. Vascular. 2005 May-Jun. 13(3):158-63. [Medline].

  8. Schroeder JW, Baskaran V, Aygun N. Imaging of traumatic arterial injuries in the neck with an emphasis on CTA. Emerg Radiol. 2009 Oct 2. epub ahead of print. [Medline].

  9. Fox CJ, Gillespie DL, Weber MA, Cox MW, Hawksworth JS, Cryer CM, et al. Delayed evaluation of combat-related penetrating neck trauma. J Vasc Surg. 2006 Jul. 44(1):86-93. [Medline].

  10. Kolber MR, Aspler A, Sequeira R. Conservative management of laryngeal perforation in a rural setting: case report and review of the literature on penetrating neck injuries. CJEM. 2011 Mar. 13(2):127-32. [Medline].

  11. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. World J Surg. 2006 Jul. 30(7):1265-8. [Medline].

  12. Rezende-Neto J, Marques AC, Guedes LJ, Teixeira LC. Damage control principles applied to penetrating neck and mandibular injury. J Trauma. 2008 Apr. 64(4):1142-3. [Medline].

  13. Weppner J. Improved mortality from penetrating neck and maxillofacial trauma using Foley catheter balloon tamponade in combat. J Trauma Acute Care Surg. 2013 Aug. 75(2):220-4. [Medline].

  14. Ahmed A. Selective observational management of penetrating neck injury in northern Nigeria. S Afr J Surg. 2009 Aug. 47(3):80, 82-5. [Medline].

  15. Demetriades D, Theodorou D, Cornwell E 3rd, et al. Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow Doppler imaging. Arch Surg. 1995 Sep. 130(9):971-5. [Medline].

  16. Demetriades D, Theodorou D, Cornwell E, et al. Transcervical gunshot injuries: mandatory operation is not necessary. J Trauma. 1996 May. 40(5):758-60. [Medline].

  17. Gonzalez RP, Falimirski M, Holevar MR, et al. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma. 2003 Jan. 54(1):61-4; discussion 64-5. [Medline].

  18. Kendall JL, Anglin D, Demetriades D. Penetrating neck trauma. Emerg Med Clin North Am. 1998 Feb. 16(1):85-105. [Medline].

  19. Kuehne JP, Weaver FA, Papanicolaou G, et al. Penetrating trauma of the internal carotid artery. Arch Surg. 1996 Sep. 131(9):942-7; discussion 947-8. [Medline].

  20. Mattox K, Feliciano DV, Moore EE. Penetrating and blunt neck trauma. Trauma. 4th ed. Appleton and Lange; 1999. 437-450.

  21. McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg. 1994. 27:97-127. [Medline].

  22. Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. 2005 Feb. 58(2):413-8. [Medline].

  23. Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma. 2008 Jun. 64(6):1466-71. [Medline].

  24. Rostomily RC, Newell DW, Grady MS, et al. Gunshot wounds of the internal carotid artery at the skull base: management with vein bypass grafts and a review of the literature. J Trauma. 1997 Jan. 42(1):123-32. [Medline].

  25. Sclafani SJ, Scalea TM, Wetzel W, et al. Internal carotid artery gunshot wounds. J Trauma. 1996 May. 40(5):751-7. [Medline].

  26. Tisherman SA, Bokhari F, Collier B, Cumming J, Ebert J, Holevar M, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008 May. 64(5):1392-405. [Medline].

A Zone II penetrating neck injury in a young boy. This child fortunately had no other documented injuries.
Tribal violence in Kenya resulted in this zone II arrow injury.
Same patient as in Media file 2. Note the entry point and the palpable tip of the arrow in the posterior triangle.
Same patient as in Media file 2. The arrow has been removed after negative neck exploration.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.