Neck Trauma Management Guidelines

Updated: Oct 14, 2022
  • Author: David B Levy, DO, FAAEM; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines Summary

The American College of Radiology (ACR) has published the following recommendations [48] :

  • In patients with clinical soft injury signs and in patients with hard signs of injury who do not require immediate surgical exploration, computed tomographic angiography (CTA) of the neck is the preferred imaging procedure to evaluate the extent of injury.
  • When there remains clinical concern for vascular injury despite a normal or equivocal CTA of the neck, catheter-based arteriography is useful for further evaluation.
  • The benefit of arteriography is the ability to perform, in tandem, an endovascular procedure if needed.
  • If there remains a concern for aerodigestive injury despite a normal or equivocal CTA of the neck, an x-ray single contrast esophagram may be considered, but it should be used in conjunction with direct visualization techniques. 
  • MRI, in particular fat-suppressed T2-weighted imaging, is more sensitive than CT or CTA for assessing potential cartilaginous and fibrous injuries but is relegated to specific problem-solving cases and is not routinely performed.

Western Trauma Association guidelines for neck trauma include the following [49] :

  • Initial management of patients with penetrating neck injury, which violates the platysma, should follow the advanced trauma life support guidelines.

  • Patients who during their primary survey demonstrate "hard signs" or hemodynamic instability require expeditious transfer to the operating room delayed only by securing an unstable airway, with a surgical airway if attempts at oral-tracheal intubation are unsuccessful, and attempting tamponade of active bleeding while en route.

  • Most penetrating neck injuries can be approached via an anterior sternocleidomastoid incision.

  • Zone I neck injuries may require a median sternotomy with extension to an anterior sternocleidomastoid incision or supraclavicular incision with or without clavicular head resection.

  • For zone II transcervical injuries, a transverse cervical collar incision may provide access to both sides of the neck, with the potential to extend along the anterior sternocleidomastoid muscle.

  • Zone III represents a difficult anatomic zone of injury for distal vascular control. At times, subluxation, dislocation, or resection of the mandible may be necessary to gain operative vascular control.

  • Patients without indications for mandatory neck exploration who remain hemodynamically stable can be managed expectantly with observation/serial examinations or undergo further radiographic evaluation, depending on the level of suspicion for injury, the symptoms demonstrated by the patient, and the anatomic zone of injury.

  • Zone I patients without indications for neck exploration should undergo CTA of the chest and neck to evaluate for both vascular and aerodigestive injuries.

  • In hemodynamically stable patients with CTA evidence of zone I injury, further intervention is typically required. Successful endovascular approaches for arterial injuries using covered stents for zone I injuries have been documented.

  • Hemodynamically stable patients with documented zone I aerodigestive injury by CTA should undergo prompt operative intervention in most cases because this is associated with better outcome.

  • Patients with symptomatic zone II injuries should undergo early operative neck exploration by either the standard anterior sternocleidomastoid incision or cervical collar incision, depending on the nature of the injury.

  • In hemodynamically stable patients with CTA evidence of zone II injury, operative intervention is typically required because access is simple and repairs are definitive.

  • Hemodynamically stable zone III patients with suspicion for injury should undergo CTA of the neck and head to evaluate for vascular and aerodigestive injuries.