Question Of The Day #69

The neck is a compact anatomical area with many vital structures, including blood vessels that provide oxygen to the brain, the aerodigestive tracts (trachea and esophagus), nerves, and the apices of the lungs.  A penetrating injury to the neck can be catastrophic and requires prompt examination and appropriate management.  The neck is divided into 3 anatomical zones, and each zone houses different anatomical structures.  Zone 1 is from the clavicle to the cricoid cartilage, Zone 2 is from the cricoid cartilage to the mandible, and Zone 3 is from the angle of the mandible to the base of the skull.  See the reference below for pictures and further descriptions of each zone.

The presence of any “hard signs” of aerodigestive or neurovascular injury should prompt emergent operative management.  These “hard signs” include airway compromise, expanding or pulsatile hematoma, active and brisk bleeding, hemorrhagic shock, neurological deficit, massive subcutaneous emphysema, and air bubbling through the wound.  If the patient is hemodynamically stable and does not have any of these dangerous “hard signs”, it is reasonable to pursue CT angiography of the neck (Choice A) to evaluate for any vascular, aerodigestive, or neurologic injuries.  The fish should not be removed (Choice B) in the Emergency department as this may result in uncontrolled bleeding.  A more controlled environment, like an operating theater, is a more appropriate setting to remove a penetrating foreign body.  The patient in this case has 2 hard signs (bubbling through wound and airway compromise), so he will need operative management (Choice C).  However, the patient’s airway compromise is a more emergent and time-sensitive issue that needs to be addressed first with endotracheal intubation (Choice D).  Intubation is the next best step in management.  Correct Answer: D