Clinical Practice Guideline:
Penetrating Zone II Neck Trauma
J Trauma. 2008;64:1392–1405.
- Is mandatory operative management or selective operative management appropriate?
Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations.Level II:
High resolution CTA offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available.
- Can duplex ultrasonography or CTA rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary?
CTA or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck.Level III:
CT of the neck (even without CTA) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed.
- Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury?
Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours.
- Is physical examination sensitive enough to rule out injuries to vascular structures or the aerodigestive tract?
Careful physical examination using protocols for serial examinations, including auscultation of the carotid arteries, is 95% sensitive for detecting arterial and aerodigestive tract injuries that require repair. Given the potential morbidity of missed injuries, clinicians should have a low threshold for obtaining imaging studies.