Neck Exploration (Penetrating Trauma)
What the Examiner Expects
Surgical exploration of the neck for penetrating trauma, classically divided by zones. The examiner expects you to know the three zones of the neck, recognize hard signs of vascular injury (active hemorrhage, expanding hematoma, absent pulses, bruit/thrill) and aerodigestive injury (massive hemoptysis, air bubbling through the wound, subcutaneous emphysema), and understand the shift from mandatory exploration to selective management with CTA. Hard signs mandate immediate operative exploration regardless of zone. For stable patients without hard signs, CTA of the neck provides excellent evaluation of vascular, aerodigestive, and spine injuries. Zone II is approached through an incision along the anterior border of the sternocleidomastoid muscle.
Key Examiner Focus Points
- Zone I (clavicle to cricoid): most dangerous — great vessels, thoracic inlet structures
- Zone II (cricoid to angle of mandible): most common; traditionally explored if platysma is violated
- Zone III (angle of mandible to skull base): difficult surgical access; angiography preferred
- Modern approach: CT angiography for all zones — selective exploration based on findings
- Hard signs (active hemorrhage, expanding hematoma, air bubbling, massive hemoptysis): immediate OR
Common Curveballs
Stab wound to zone II with an expanding hematoma — CTA is not available
Hard sign — take directly to the OR for neck exploration. Incision along the anterior border of the SCM. Prepare for proximal and distal vascular control. Do not delay for imaging when hard signs are present.
CTA shows a zone I injury to the subclavian artery
Zone I vascular injuries often require thoracic exposure for proximal control. Options: median sternotomy (right subclavian), left anterolateral thoracotomy or trapdoor incision (left subclavian), or endovascular stent grafting if the patient is stable and the injury is amenable.
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