Penetrating neck injuries & blunt cerebrovascular injuries (BCVI)

Platysma Violation

• If the platysma is not breached, a serious injury is effectively excluded.
• If the platysma breach cannot be confidently excluded, further investigation with CT angiography is indicated.
• Visual inspection is unreliable- always consider trajectory, bleeding, and associated signs when deciding on imaging.

Anatomical Zones

While the traditional zones still provide anatomical context, management should be guided by clinical signs and imaging, not zone location alone:

Zone 1: Clavicles and sternal notch to cricoid cartilage
Zone II: Cricoid cartilage to the angle of the mandible
Zone III: Angle of mandible to base of skull.

• Early airway assessment is essential; anticipate the need for definitive airway.
• Apply direct pressure, consider haemotastic dressings and/or the use of a Foley catheter to tamponade bleeding
• Avoid blind clamping
• Perform and document a full neurovascular exam.

Perform CT Angiography (CTA) of the neck and chest in:

• All stable patients with hard or soft signs
• All patients with penetrating neck injuries considered for non-operative management.

If aerodigestive tract injury is suspected despite normal/equivocal CTA:

• Consider barium swallow in conjunction with laryngoscopy/ esophagoscopy
• Consider ENT or cardiothoracic input early.

Zero 1 injuries may require thoracotomy for proximal control. 

• Haemodynamically unstable with hard signs
• Active haemorrhage or expanding haematoma
• Confirmed aerodigestive tract or vascular injury
• Retained foreign body

Non operative management may be appropriate in selected patients who meet ALL of the following:

• Haemodynamically stable
• No hard signs of vascular injury or aerodigestive injury
• Negative or equivocal imaging
• Reliable clinical examination and monitoring available

Screen with CTA neck from aortic arch to skull base in blunt trauma patients with ANY of the following:

Signs/Symptoms

• Arterial bleeding from neck/nose/mouth
• Cervical bruit (especially <50 years)
• Expanding cervical haematoma
• Neuroligcal deficit not explained by CT head
• Stroke on imaging
• TIA, hemiparesis, Horners syndrome

Mechanism/Risk Factors

High energy mechanism with:

• Le Fort II/III facial fractures
• Mandible fracture
• Basilar skull/occipital condyle fracture
• Unstable cervical spine fracture
• Clothesline or seatbelt neck injury
• Near-hanging
• TBI with thoracic trauma
• Upper rib fractures or clavicular trauma
• Scalp degloving

Extended Denver Criteria

Use CTA for initial diagnosis. Consider MRI/MRA or DSA if CTA is equivocal or symptoms progress

Grading (Biffl classification)

• Grade I (intimal injury <25% narrowing)
• Grade II (dissection or intramural haematoma >25%)
• Grade III (pseudoaneurysm)
• Grade IV (occlusion)
• Grade V (transection with extravasation) 

• Endovascular options include: stenting or embolisation
• Surgery is rare but may be required in select penetrating injuries or grade V BCVI

• Repeat CTA in 7-10 days for all conservatively managed injuries (Grades I-IV)
• Continue antiplatelet therapy for 3-6 months if repeat imaging shows persistent injury
• All patients with BCVI should have neurology follow up and blood pressure control.