AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Penetrating neck trauma is an important area of trauma care that has undergone evolution in the recent past. A remarkable number of changes have occurred in the treatment paradigm as new technologies have developed and as surgeons have explored the outcomes from different treatment protocols. Therapy has evolved from no treatment (prior to effective anesthesia and instrumentation), to nonoperative management, to routine exploration, to selective exploration and adjunctive invasive or noninvasive assessment.

History of the Procedure

In 1552, Ambrose Pare ligated both common carotid arteries and the jugular vein of a soldier with a traumatic neck injury. The patient survived but developed aphasia and hemiplegia.

In 1803, Fleming ligated a lacerated common carotid artery and reported a successful outcome with a 5-month follow-up.

Nonoperative management of penetrating neck wounds was the standard until World War I. During World War II, a more aggressive approach to neck exploration was adopted. Continual advances in anesthesia and perioperative management since World War II have improved the care and outcome of these patients.

Problem

Penetrating neck trauma involves a missile or sharp object penetrating the skin and violating the platysma layer of the neck. This includes gunshot wounds, stab or puncture wounds, and impalement injuries.

Frequency

Penetrating neck trauma represents approximately 5-10% of all trauma cases that present to the emergency department. About 30% of these cases are accompanied by injury outside of the neck zones as well. The current mortality rate in civilians with penetrating neck injuries ranges from 3-6%. During World War II, the mortality rate was 7%, and, in World War I, it was 11%. Higher mortality rates occur with injuries to large vessels, such as the carotid or subclavian arteries and veins.

Etiology

Penetrating neck injuries, like any trauma, may be classified as intentional or nonintentional. The objects causing these injuries can be divided into stabbing instruments (eg, knives, cutting instruments, puncturing objects, impaling objects) and shooting instruments (eg, missiles, projectiles). Wounding instruments have specific characteristics that affect surgical findings. For example, stab wounds typically have a 10% higher rate of negative exploration than injuries from projectiles.

Pathophysiology

Two factors in the mechanism of injury or kinematics in penetrating neck trauma determine the extent of damage to the tissue.

• Weapon characteristics
  • The amount of kinetic energy delivered by the wounding agent has to be considered together with its interaction with the involved tissue.
  • Kinetic energy (KE) is described by the following equation: KE = mass X velocity (squared)
  • Low-energy weapons include hand-driven weapons, such as knives or ice picks, which damage with only their sharp point or cutting edge.
  • Firearms may be classified as medium-energy (ie, handguns) and high-energy weapons (ie, military assault weapons), with the latter usually defined as having 461 joules or more.
  • Projectiles (ie, bullets, missiles) often are differentiated by mass, velocity, shape, and construction because these characteristics affect the extent of tissue disruption.
  • Bullet velocity is the most important characteristic considered, with high velocity defined as greater than 2500 ft/s.
• Location of injury and human tissues involved
  • Tissue injury results from either a direct impact by the penetrating projectile or tissue displacement from temporary cavitation.
  • Wound sites and, if present, the wounding agent in the neck provide an indication of the likely injury complex.

Clinical

Evidence of significant injury to vital structures of the neck may be indicated by the following clinical manifestations:

• Active external hemorrhage from the wound site – Arterial vascular injury
• Hematoma (expanding) – Vascular injury
• Bruit/thrill – Arteriovenous fistula
• Stridor – Laryngeal and/or esophageal injury
• Dysphagia – Tracheal and/or esophageal injury
• Hoarseness – Tracheal and/or esophageal injury (especially recurrent laryngeal nerve)
• Subcutaneous emphysema – Tracheal, esophageal, or pulmonary injury
• Oronasopharyngeal bleeding – Vascular, tracheal, or esophageal injury
• Neurologic deficit – Vascular and/or spinal cord injury
• Hypotension or pulse deficit – Nonspecific; may be related to the neck injury or may indicate trauma elsewhere

The evaluation of a patient with penetrating neck trauma always should start with advanced trauma life support (ATLS), a paradigm that begins with a directed primary survey emphasizing airway, breathing, and circulation (ABC). After patients are stabilized, they undergo a secondary survey that includes a complete history and thorough physical examination. These steps, together with the studies discussed in Workup, are used to identify the likely injury complex and direct further treatment or diagnostic testing.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

The standard of care is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. The type of incision depends on the neck zone and the structures at risk for injury.

The following specific injuries must be confirmed and treated during neck exploration:

• Carotid artery injuries
• Vertebral artery injuries
• Jugular vein injury
• Laryngotracheal injuries
• Esophageal injuries
• Nerve injuries
• Thoracic duct injuries
• Thyroid injuries

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

In few other regions of the body are so many vital structures (that would be of immediate concern following injury) located in so small a volume. An injury is not considered to have penetrated the neck unless the injury penetrates the platysma muscle layer. Injuries through the platysma and injuries crossing the midline usually cause a greater degree of damage. The sternocleidomastoid muscle delineates the posterior and anterior regions of the neck. The area of the neck posterior to the cervical vertebral body and the scalene muscles is composed mainly of muscle, bone, and nonvital vessels and lymphatics. Most of the vital structures are located in the anterior or lateral regions.

The neck may be divided into 3 zones using anatomic landmarks. Each zone has a group of vital structures that can be injured and may determine the kind of trauma management.

• Zone I is the horizontal area between the clavicle/suprasternal notch and the cricoid cartilage encompassing the thoracic outlet structures. The proximal common carotid, vertebral, and subclavian arteries and the trachea, esophagus, thoracic duct, and thymus are located in zone I.
• Zone II is the area between the cricoid cartilage and the angle of the mandible. It contains the internal and external carotid arteries, jugular veins, pharynx, larynx, esophagus, recurrent laryngeal nerve, spinal cord, trachea, thyroid, and parathyroids.
• Zone III is the area that lies between the angle of the mandible and the base of the skull. It has the distal extracranial carotid and vertebral arteries and the uppermost segments of the jugular veins.

Tight fascial compartments of neck structures may limit external hemorrhage from vascular injuries, minimizing the chance of exsanguination. However, these tight fascial boundaries may increase the risk of airway compromise because the airway is relatively mobile and compressible by an expanding hematoma.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

No role exists for probing or local exploration of the neck in the trauma bay or emergency department because this may dislodge a clot and initiate uncontrollable hemorrhage. If no significant injuries requiring surgery are present, surgical therapy is unnecessary and observation or expectant management may proceed.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Lab Studies

• 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

• 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 in zone I and zone III, as well as selectively managed zone II 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 III despite hypotension or hemorrhage. Angiography remains the criterion standard for defining arterial anatomy and injury complexes, with 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,thistechniquemayreplaceangiography.
• Two-dimensional Doppler studies are a noninvasive alternative to angiography to evaluate vascular injury in evaluable zones (principally zone II). 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 available increasingly but require costly imaging systems that may not be readily available in the emergency department. Such tests may be utilized best 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 defining and diagnosing laryngeal injury. A CT scan does not increase the sensitivity of detecting esophageal injury. If esophageal injury is suspected, esophagoscopy is the procedure of choice.
• Magnetic resonance imaging: The advantage 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.

Diagnostic Procedures

• 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 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.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Medical therapy

• Prehospital care
  • Resuscitative efforts are imperative, with the emphasis on the ABCs.
  • The airway is cleared of any obstruction and assessed for possible injury.
  • A depressed sensorium and demonstrated poor oxygenation and ventilation are indications to establish a more optimal airway (ie, through endotracheal intubation) and possibly start mechanical ventilation.
  • Control of bleeding with direct pressure on the wound site is adequate initially. Large-bore intravenous catheters for fluid resuscitation are inserted. Recent studies suggest that resuscitation targets with regard to blood pressure be lowered to the range of a mean arterial pressure of 50 mm Hg until definitive hemorrhage control is possible. The concern is that aggressive resuscitation may elevate the blood pressure and increase hemorrhage through an uncontrolled injury site.
  • Cervical spine precautions are implemented with suspected spinal cord injury, but these are rare.
  • Expeditious transport to an adequate emergency care facility is warranted
• Medical therapy
  • To secure a definitive airway, translaryngeal endotracheal intubation should be performed in penetrating neck injuries accompanied by respiratory failure or in cases in which urgent exploration is necessary.
  • If translaryngeal intubation fails, as occurs in extensive facial or mandibular fractures, a cricothyroidotomy may be required. Expeditious intubation of a tracheotomy produced by the penetrating injury sometimes may be lifesaving.
  • Adequate ventilation and oxygenation usually entails invasive mechanical ventilation. Noninvasive ventilation has little role in treating patients with penetrating neck trauma.
  • A warmed balanced sodium chloride solution (ie, Ringer lactate) is the initial resuscitation fluid of choice. Colloid resuscitation strategies may include starch products or component products for transfusion of red blood cells or clotting factors as appropriate.
  • Evaluate and monitor the neurologic status of the patient with consideration for spinal cord injury, as well as vascular trauma with cerebral circulatory compromise.
  • After the primary survey and resuscitation and stabilization of the patient (if possible without an operation), attention is directed to the identification of specific injuries to determine whether surgical treatment is indicated. If no significant injuries requiring surgery are present, observation or expectant management may proceed.

Surgical therapy

The standard of care is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. Surgical management varies in difficulty depending on the area of neck injury. Surgical exposure of the injury is particularly difficult in zones I and III. Vascular control may be problematic in zone I (proximal control) and zone III (distal control). This consequently leads to the higher mortality rates in patients with vascular injuries in these neck zones.

Preoperative details

Continue resuscitative efforts and establish a complete list of possible injuries, by diagnostic tests if necessary. Other sites of injury include the adjacent thorax and head or other distant body parts in multiple injuries. Preparation for surgery also includes tetanus prophylaxis, antibiotic prophylaxis (gram-positive coverage), and a specimen for blood typing should component therapy be required.

Intraoperative details

The type of incision depends on the neck zone and the structures at risk for injury. An additional consideration is proper exposure to gain adequate proximal and distal control of involved blood vessels. The standard neck incision, parallel the medial border of the sternocleidomastoid muscle, can be used for most injuries in zone II and can be extended cephalad for zone III injuries, specifically, injuries to the distal carotid or vertebral arteries. Extension of the standard neck incision, transversely to the opposite side, can be performed for bilateral injuries.

A transverse, or collar-type, incision can be performed for suspected injuries traversing the cervical region, providing exposure to both sides and obviating the need for bilateral neck incisions.

A supraclavicular incision provides good exposure for zone I injuries. Removal of the head of the clavicle with an oscillating saw may provide better exposure. In conjunction, an anterolateral thoracotomy incision also may be used for thoracic inlet injuries.

The trapdoor, or open-book, thoracotomy includes a median sternotomy with an anterolateral extension and a supraclavicular extension for more exposures of zone I injuries.

The following specific injuries must be confirmed and treated during neck exploration. Note that multiple structures frequently are injured from penetrating neck injury due to the numerous vital structures that are contained in a small area.

Carotid artery injuries are the most common, with an incidence of approximately 9%. They also pose one of the most immediate life-threatening situations. The objective of surgical care is to arrest hemorrhage yet maintain cerebral blood flow and preserve neurologic function. Arteriorrhaphy, vein patch, or segmental repair with autogenous reversed saphenous vein graft can be performed to repair the injury. Arterial repair is shown to have lower morbidity and mortality rates than ligation. The presence of neurologic deficits, coma, and shock, especially preoperatively, are poor prognostic signs but are not absolute contraindications for carotid artery repair. Carotid ligation is advocated in comatose patients with no evidence of antegrade flow in the internal carotid artery. Ligation also can be an option when uncontrollable hemorrhage is present and temporary shunt placement is technically difficult.

Vertebral artery injuries have been diagnosed with increasing frequency with liberal use of arteriography, particularly 4-vessel angiography. The treatment of choice in the well-perfused patient is expectant management. Definitive intervention is indicated if a pseudoaneurysm, an arteriovenous fistula, or persistent bleeding is documented. Surgical repair can be performed, but, if the circle of Willis is patent, ligation is always an option. Angiographic embolization has advantages for this difficult-to-access artery, but distal control is still a problem.

Jugular vein injury repair is contingent on the condition of the patient. Repair can be performed by simple lateral closure, resection and reanastomosis, or saphenous vein graft reconstruction, particularly the internal jugular. Repairing at least one side is very important if both internal jugular veins are injured. The external jugular vein can be ligated without any adverse effects.

Laryngotracheal injuries also are common, with a combined incidence of 10% among cases of penetrating neck trauma. Tracheal injuries can be repaired primarily in one layer of sutures. Interposition of adjacent omohyoid or sternocleidomastoid muscles should be performed when esophageal and arterial repair to prevent fistula formation are performed concomitantly. Tracheostomy is indicated when injury is severe, but performing it through the site of surgical repair should be avoided. A soft intralaryngeal stent in extensive disruption of the cartilaginous support of the larynx is recommended.

Esophageal injuries are the third most common in penetrating neck trauma (6%). Signs and symptoms of dysphagia, hematemesis, subcutaneous crepitus, retropharyngeal air, and injuries to adjacent structures are strong indicators of esophageal injury. Early diagnosis lessens the probability of delayed treatment and missed injury, which can be devastating (ie, mediastinitis). The recommended management of esophageal injury is primary repair and adequate drainage. Oral feeding may be initiated after a barium swallow study shows no evidence of a leak. For extensive injuries or in cases of delayed diagnosis with significant infection, the better option is to establish a controlled fistula with catheter drainage or an esophagostomy. Hypopharyngeal wounds sometimes can be treated with just a nasogastric tube for feeding and parenteral antibiotics. Feeding can be through a feeding jejunostomy or parenteral nutrition.

Nerve injuries account for about 1-3% of cases of penetrating neck trauma. Injury to the vagus, recurrent laryngeal nerve, or brachial plexus should be repaired primarily when feasible (ie, a well-perfused patient without active hemorrhage). Spinal cord injury caused by penetrating trauma is managed expectantly. Steroids have not been shown to benefit injury from penetrating neck trauma.

Thoracic duct injuries, albeit difficult to demonstrate, can occur. They should be ligated to prevent chylous fistula and infections in the neck and mediastinum.

Thyroid injuries are uncommon despite the thyroid's size and location in the neck. Injuries can cause significant bleeding that often is controlled with direct pressure or suture ligation. Extensive injury may require an ipsilateral lobectomy to resolve the bleeding.

Postoperative details

Vascular injuries are managed postoperatively to ensure hemorrhage is stopped and blood supply and drainage to affected organs is adequate. Continually monitor the neurologic status of the patient. Ancillary angiographic and Doppler ultrasound studies can be performed to evaluate suspected complications with the repaired vessels.

Demonstration of good oxygenation and ventilation and the ability to maintain a patent airway are the parameters generally used to remove ventilatory support and extubation. Repairs of laryngotracheal injuries may require flexion of the neck to reduce tension.

A barium swallow study is performed after 5-7 days to evaluate the integrity of an esophageal injury repair. Oral feeding is initiated if no evidence of leak is present. The drains and feeding tubes also are discontinued. Parenteral antibiotics often are administered for the same duration. For those with controlled fistulas, definitive repair is performed after resolution of infection. Uncontrolled fistulae require the placement of additional drains and possible reexploration. Reexploration is performed for uncontrolled sepsis, as well as failure of percutaneous drainage methods.

Follow-up

After the initial postoperative recovery period, the patient should be monitored closely for complications. Breakdown of surgical repairs occasionally may occur. A high level of suspicion is needed for the early detection of postoperative complications or the need for diagnostic tests to confirm or rule out suspected problems. Long-term sequelae are uncommon. Cervical esophageal stenosis is rare but is treated adequately by bougienage.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Missed injuries or delayed diagnosis can occur after any injury to the neck, particularly in patients presenting with minimal manifestations.

• Persistent hemorrhage - Usually from a missed arterial or venous injury particularly in zone III and I
• Pseudoaneurysms - A later sequela from a missed vascular injury, which often is not bleeding actively during treatment
• Arterial dissection - Incomplete transmural vessel injury may cause this disruption between the layers of the arterial wall.
• Fistulas - Esophagocutaneous, esophagotracheal, tracheocutaneous, venoarterial
• Infections - Most often occur from missed esophageal or laryngotracheal injuries, severe inflammation, abscess formation, or mediastinitis may result
• Stenosis or obstruction of luminal structures - May happen due to the inflammatory response and scarring around the injured esophagus, larynx, trachea, or vessels
• Neurologic deficits - May occur due to the direct injury to a peripheral nerve or to ischemic infarct caused by arterial injury
• Anastomotic or repair disruption - About 1% of surgical repairs leak and result in hemorrhage, infection, or fistula formation.
• Luminal stenosis or obstruction - The surgical repair and the inflammation can cause the narrowing of the lumen of the injured esophagus, larynx, trachea, or vessels.
• Infectious complications - Occurring particularly with injuries to the trachea and esophagus, severe inflammatory response in the neck, abscess formation, fistulas, or mediastinitis may result.
• Neurologic complications - Can occur as strokes related to major vascular injuries or directly to peripheral nerves
• Thrombosis of an internal jugular vein - Can occur regardless of the method of venorrhaphy
• Massive air emboli - May result from major venous injuries and is an important cause of bilateral, diffuse stroke identified as hypodense lesions on CT scan of the brain

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Vascular trauma is present in 25% of penetrating neck injuries, with mortality rates approaching 50% in some studies. Tracheobronchial injuries may have an incidence less than 10% to as high as 20% and a mortality rate 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

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

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, 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 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.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

• Demetriades D, Theodorou D, Cornwell E 3rd. Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow doppler imaging. Arch Surg. Sep 1995;130(9):971-5. [Medline].
• Demetriades D, Theodorou D, Cornwell E. Transcervical gunshot injuries: mandatory operation is not necessary. J Trauma. May 1996;40(5):758-60. [Medline].
• Gonzalez RP, Falimirski M, Holevar MR. 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. Jan 2003;54(1):61-4; discussion 64-5. [Medline].
• Kendall JL, Anglin D, Demetriades D. Penetrating neck trauma. Emerg Med Clin North Am. Feb 1998;16(1):85-105. [Medline].
• Kuehne JP, Weaver FA, Papanicolaou G. Penetrating trauma of the internal carotid artery. Arch Surg. Sep 1996;131(9):942-7; discussion 947-8. [Medline].
• Mattox K, Feliciano DV, Moore EE. Penetrating and blunt neck trauma. In: Trauma. 4th ed. Norwalk, Conn:. Appleton and Lange;1999:437-450.
• McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg. 1994;27:97-127. [Medline].
• Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. Feb 2005;58(2):413-8. [Medline].
• Rostomily RC, Newell DW, Grady MS. Gunshot wounds of the internal carotid artery at the skull base: management with vein bypass grafts and a review of the literature. J Trauma. Jan 1997;42(1):123-32. [Medline].
• Sclafani SJ, Scalea TM, Wetzel W. Internal carotid artery gunshot wounds. J Trauma. May 1996;40(5):751-7. [Medline].

Article Last Updated: Dec 19, 2006