There were 225 patients with penetrating neck wounds admitted over a 4-year period. Mechanism of injury included stab wounds in 59%, gunshot wounds in 32%, and shotgun wounds in 9%. Location of injury was Zone 1, 16%, Zone 2, 42%, Zone 3, 18%, posterior triangle, 12%, and multiple, 12%. The patients were divided into five groups based upon clinical presentation, location of injury and method of management: Group 1 (n=31) had serious blood loss or respiratory distress and were immediately explored; Group 2 (n=76) had anterior wounds and equivocal physical findings either without (n=60) or with negative (n=16) contrast studies and these had "mandatory explorations"; Group 3 (n=17) and Group 4 (n=80) presented the same as Group 2 but Group 3 patients had positive contrast studies and were explored, while contrast studies were negative in Group 4 patients who were observed; Group 5 (n=21) had posterior injuries and/or presented late with minimal physical findings and they were observed. Positive exploration occurred in 90% of Group 1, 28% of Group 2, and 82% of Group 3. There were no missed in Groups 4 or 5. Two missed esophageal injuries occurred in Group 2, and a missed carotid injury occurred in Group 3. The following guidelines for management have resulted. 1) Unstable patients require immediate exploration. 2) Stable patients with equivocal physical findings can be managed according to results of esophageal examination and angiography. 3) Patients with low probability of injury due to location and clinical presentation can be observed. 4) Regardless of method of management, those with a possibility of esophageal injury should undergo esophagram and/or esophagoscopy.
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