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Clinical Practice Guideline: Penetrating Zone II Neck Trauma

Tisherman, Samuel A. MD; Bokhari, Faran MD; Collier, Bryan DO; Cumming, John MD; Ebert, James MD; Holevar, Michele MD; Kurek, Stanley DO; Leon, Stuart MD; Rhee, Peter MD

The Journal of Trauma: Injury, Infection, and Critical Care: May 2008 - Volume 64 - Issue 5 - p 1392-1405
doi: 10.1097/TA.0b013e3181692116
Brief Review
Free

From the Departments of Surgery and Critical Care Medicine (S.A.T.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Trauma (F.B.), Stroger Hospital of Cook County, Chicago, Illinois; Department of Surgery (B.C.), Vanderbilt University, Nashville, Tennessee; Department of Emergency Medicine (J.E.), Elmhurst Memorial Healthcare, Elmhurst, Illinois; Department of Surgery (M.H.), Mount Sinai Hospital, Chicago, Illinois; Department of Surgery (J.C.), Stamford Hospital, Stamford, Connecticut; Department of Surgery (S.K.), University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee; Department of Surgery (S.L.), Medical University of Southern Carolina, Charleston, South Carolina; and Department of Surgery (P.R.), University of Arizona, University Medical Center, Tucson, Arizona.

Submitted for publication July 19, 2007.

Accepted for publication December 18, 2007.

Address for reprints: Samuel A. Tisherman, MD, Department of Critical Care Medicine, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261; email: tishermansa@upmc.edu.

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STATEMENT OF THE PROBLEM

Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent on the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds.

The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The neck has been divided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common1 and can affect length of stay.2 Mortality, particularly for major vascular injuries may reach 50%.3 Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes.4 Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated. Controversy arises over management of the patient without significant symptoms. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Mandatory exploration, while seemingly safe and conservative, led to many nontherapeutic operations. This fact, along with advances in technology, such as high resolution computed tomography (CT), may eliminate the need to explore the neck to determine whether there are injuries. Also during the time that technology had been advancing, many reports have documented the safety of selective management of neck injuries that penetrate the platysma. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. This guideline was therefore initiated to examine the specific roles of mandatory exploration versus selective management based on physical examination and current imaging technologies for penetrating neck trauma.

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Goals of the Guideline

This guideline is designed to answer the following questions regarding the management of penetrating injuries to zone II of the neck that penetrate the platysma.

  1. Is mandatory operative management or selective operative management appropriate?
  2. Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary?
  3. Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury?
  4. Is physical examination sensitive enough to rule out injuries to vascular structures or the aerodigestive tract?
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PROCESS

The process used by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed on the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2007.

Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the United States Department of Health and Human Services as follows: Class I—prospective, randomized, double-blinded study; Class II—prospective, randomized, nonblinded trial; or Class III—retrospective series, meta-analysis.

An evidentiary table (Table 1) was constructed using the 112 references that were identified: Class I, 1 reference; Class II, 30 references; and Class III, 81 references. Recommendations were made on the basis of the studies included in this table. Level I recommendations, usually based on Class I data, were meant to be convincingly justifiable on scientific evidence alone. Level II recommendations, usually supported by Class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level III recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.

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RECOMMENDATIONS

Selective Workup—Operation Versus Selective Nonoperative Management

Recommendations

  • Level I: Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations.
  • Level II: High resolution CT angiography offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available.
  • Level III: No recommendations.
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Scientific Foundation

Nonoperative management of penetrating neck wounds was common in the early 20th century. Based on a review of civilian experience, Fogelman and Stewart5 recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. The rationale was that a significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries.6 In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al.7 estimated the cost of a negative exploration at $1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al.8 found that neck explorations under local anesthesia, compared with general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable.9,10

Mandatory exploration gained in popularity as studies showed that clinical symptoms were not present in 0% to 23% of the cases. However, mandatory exploration was negative 53% to 60% of the time and did not identify any injuries. In addition, some of the clinically silent injuries were venous and pharyngoesophageal injuries, which did not require operative therapy.11–13

Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed,14–34 though observation for up to 48 hours may be necessary,35 depending on the use of ancillary tests. Jurkovich et al.36 compared the results of mandatory exploration (the preference of the attending surgeon) in 47 patients with a selective approach in 53 patients using 43 angiograms and 14 endoscopies. In the mandatory exploration group, the negative exploration rate was 53%. In the selective approach group, 12 injuries were found but only five patients benefited from the work up. Some studies specifically recommended that to manage penetrating neck injuries, a well-staffed teaching hospital with a trauma service and immediate availability of radiologic and endoscopic evaluations is needed.37 However, it has been shown that selective management can be safe in community hospitals with experienced surgeons.38 Evidence of chest injury does not seem to be an indication for neck exploration.39

Debate on the issue of selective management continued as Meyer et al.40 questioned this new approach of selective exploration for penetrating neck injuries. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy, and esophagography in each patient before a mandatory exploration. Forty-eight injuries were identified in 35 explorations. Of concern was the fact that five patients had six major injuries that were not identified by the preoperative testing. Thus they believed that a mandatory exploration approach was indicated.

More recent studies have consistently shown that the selective approach is a safe option. In a series of 128 asymptomatic patients who were observed by Biffl et al.,41 based primarily on physical examination, only one patient had a missed injury (from an ice pick). Only 15% of these patients required adjuvant tests. Sriussadaporn et al.42 also successfully observed 17 asymptomatic patients. Only 2 of 40 patients who underwent exploration did not need the operation, though they seemed to have deep wounds. In asymptomatic patients, Nason et al.43 found that 67% underwent negative explorations. All zone II vascular injuries were symptomatic. Narrod and Moore44,45 reviewed their 10-year experience with penetrating neck trauma. In the first 6 years, mandatory exploration led to a 56% rate of negative explorations. In the next 4 years, a selective management strategy was used. Forty-one of 48 patients who underwent exploration had significant injuries,45 whereas 29 asymptomatic patients were observed without any missed injuries. Few ancillary studies were performed in this group. In a large, retrospective study from Johannesburg, South Africa, Velmahos et al.46 compared results with patients who underwent immediate surgical exploration versus constant monitoring. In the exploration group, 3% of the explorations were unnecessary; mortality was 4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%. Criteria for observation versus exploration were not clear making the interpretation of the 9% missed injury rate difficult. The only randomized trial comparing mandatory neck exploration with a selective approach based on physical examination and radiographs was performed by Golueke et al.47 in 160 patients. There was no difference in hospital stay, morbidity, or mortality.

Management of transcervical gunshot wounds deserves separate consideration because of the high likelihood of major injury.48 Hirshberg et al.49 explored 41 patients with transcervical gunshot wounds. Twenty-eight had more than one zone of the neck involved. Although seven patients did not have major injuries, 34 patients had 52 major injuries to cervical structures mainly involving vessels and the upper airway. Sixteen presented with life-threatening problems. They recommended mandatory exploration. In contrast, Demetriades et al.50 found that a selective approach based on physical examination, angiography, esophagoscopy, and esophagography was safe.

Helical CT angiography is the newest technology to be tested for identifying vascular injuries from penetrating neck trauma, particularly arterial injuries. Because it might also be useful for identifying or ruling out other injuries (e.g., aerodigestive tract injury), this modality is particularly intriguing as a “one stop shop” to evaluate asymptomatic patients for selective operative management. The speed and resolution of this modality continues to improve. Gracias et al.51 have already recommended that if a CT demonstrates trajectories that are remote from vital structures, the need for additional invasive studies can be eliminated.

In the setting of a mandatory exploration protocol, Mazolewski et al.52 found that CT angiography, compared with operative findings, was 100% sensitive and 91% specific in 14 patients. Both Munera et al.53 and Nunez et al.54 pointed out the utility of CT angiography for identifying nonvascular soft tissue injuries, and the vascular injuries. Inaba et al.55 reviewed their experience with 106 patients who had penetrating injuries to the neck. Fifteen required urgent operation. The remainder underwent CT angiogram. Two tracheal injuries and two carotid artery injuries were identified. No injuries requiring intervention were missed. Use of CT angiography can safely decrease the number of neck explorations and, more importantly, the number of negative neck explorations.56,57 In addition, CT angiography can decrease, though not eliminate, the need for formal angiography and esophagography in some patients.56

Management of neck wounds in the military setting may be different from that in the civilian world. Prgomet et al.58 found that injuries that did not penetrate the platysma did not cause significant injuries. Forty-nine of 84 patients who underwent immediate exploration had injuries to vital structures. They also found that it was safe to close the wound primarily if it was seen within 6 hours of injury. In their experience, even extensive laryngotracheal injuries could be repaired safely.59

There is little data on selective management of penetrating neck injuries in children. Small studies60,61 suggest that a selective management strategy is safe.

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Diagnosis of Arterial Injury

Recommendations

  • Level I: No recommendations.
  • Level II: CT angiography or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck.
  • Level III: CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed.
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Scientific Foundation

In the era of mandatory neck exploration for penetrating trauma, there seemed to be little need for angiography, though some9 suggested that the angiogram could assist in operative planning and thereby minimize morbidity or rule out the need for exploration.62,63 Physical examination, however, seemed unreliable for ruling out arterial injury.64 Delayed pseudoaneuryms and neurologic events have been described in originally asymptomatic patients, prompting some to advocate angiography in all such patients.65 A negative arteriogram in a stable patient can rule out an arterial injury.66 North et al.67 reviewed the records of 139 stable patients with penetrating neck trauma. Patients who had at least soft signs of vascular injury (absent pulse, bruit, hematoma, or altered neurologic status) had a 30% incidence of vascular injury by angiography, whereas only 2 of 78 asymptomatic patients had injuries (one minor and one that did not affect management). Gunshot wounds were more likely than stab wounds to cause vascular injury. Similarly, Hartling et al.68 found, using angiography, that 43 patients with stab wounds to the neck and minimal symptoms had no significant injuries. Even in the 18 patients with physical findings consistent with a vascular injury, only two had significant injuries. Similarly, Rivers et al.69 questioned the value of angiography. Of 63 angiograms in 61 patients, only 6 were abnormal. Three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by arteriography in the absence of suggestive physical findings. No major arterial injuries that were missed preoperatively were discovered during exploration. Angiograms did not alter the course of management. Noyes et al.70 examined the accuracy of a selective management strategy. Arteriography and laryngoscopy/bronchoscopy were 100% accurate.

In contrast, Sclafani et al.71 found that 10 of 26 patients who had positive angiograms for penetrating vascular injury to the neck had undergone the angiogram solely because of proximity. Physical examination had a sensitivity of 61% and specificity of 80%. They also found no differences in their results based on mechanism of injury. They suggested that proximity should not be abandoned as an indication for angiography in these patients.

Menawat et al.72 performed angiography for proximity or soft signs of vascular injury. Fifteen injuries were found on 45 angiograms. Forty-two patients without any signs of injury were successfully observed without angiography or operation. Overall, only one patient had a significant injury that was not predicted by physical examination.

In contrast, Nemzek et al.73 found that proximity, based on the addition of plain films or CT of the neck showing prevertebral soft-tissue swelling, missile fragmentation, or missiles adjacent to major vessels can be useful, but are nonspecific radiographic signs.

To examine the cost effectiveness of angiography, Jarvik et al.74 studied 111 patients with penetrating neck trauma. Forty-five of the 48 patients with vascular injuries had abnormal clinical findings. Management in the other three patients was not altered by the angiogram. They calculated the cost of screening angiography in asymptomatic patients to be approximately $3.08 million per central nervous system event.

Demetriades et al.75 prospectively compared physical examination and duplex US imaging with angiography in 82 stable patients with penetrating neck injuries. Only 11 patients had vascular injuries by angiography; and only two of these injuries needed to be repaired. The serious injuries were detected or suspected on physical examination, but six lesions that did not require treatment were missed (sensitivity 100% for serious injuries, but 45% for all injuries). By duplex US imaging, 10 of 11 injuries, including all serious ones, were identified, for an overall sensitivity of 91% (100% for clinically important lesions) and specificity of 99%. Further studies by Demetriades et al.76 included 223 patients. Of the 160 asymptomatic patients, 11 had injuries that did not require treatment. Overall, duplex US was 92% sensitive (100% for findings that required an operation) and 100% specific for defining an injury. Similarly, Bynoe et al.77 found that duplex US was 95% sensitive and 99% specific for vascular injuries after both neck and extremity trauma. The only missed injuries were two shotgun pellet injuries that did not need repair.

In a prospective, double-blind study, Montalvo et al.78 found that US identified all 10 significant injuries in 52 patients with penetrating neck trauma. Duplex US did not identify reversible carotid narrowing in one patient and did not visualize two vertebral arteries. Another report by the same group79 found in 55 patients that duplex US had 100% sensitivity and 85% specificity.

Corr et al.80 reported that duplex US picked up two intimal flaps that were not identified on angiography.

Munera et al.81 prospectively studied 60 patients, who had 10 vascular injuries. There was one missed injury by CT angiography because the study actually did not include the entire neck. They later82 suggested that patients with bruits or thrills at admission may be better treated by undergoing conventional angiography because of the potential for endovascular therapy. Helical CT angiography is limited by artifact due to metal, which may obscure arterial segments; therefore, these patients should undergo conventional angiography.

Ofer et al.83 reviewed their experience with CT angiography in 16 patients (12 with penetrating trauma and four with blunt) and found no missed injuries, although only one patient with penetrating trauma had a carotid injury (confirmed at operation).

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Diagnosis of Esophageal Injury

Recommendations

  • Level I: No recommendations.
  • Level II: Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours.
  • Level III: No recommendations.
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Scientific Foundation

The problem with penetrating injuries to the esophagus is that there are frequently no findings on physical examination. Esophagography can miss the injury.84 This is of grave concern since late referral and management can lead to significant morbidity and mortality.85–87 Early diagnosis and management, often with primary repair, lead to good outcomes.88–90 Even gunshot wounds can be closed primarily91; more complex repairs may lead to strictures.92 Location of the injury can affect outcome as injuries above the arytenoid cartilages can be managed without intervention, whereas more inferior injuries require neck drainage to prevent a deep tissue infection.93 Madiba et al.94 also found that patients with small injuries and contained perforation on contrast studies could be observed without operation unless there was another indication for exploration. All 26 patients with injuries had odynophagia. Of 17 patients managed nonoperatively, only one developed local sepsis. Six patients had associated tracheal injuries. In addition, patients with tracheal injuries have worse outcomes if they have concomitant esophageal injuries.95,96

Noyes et al.70 found that esophagograms were 90% accurate and esophagoscopy was 86% accurate. Weigelt et al.97 used a strategy of esophagography followed by rigid esophagoscopy if the esophagogram were equivocal to identify esophageal injuries in patients who had no or minimal symptoms after penetrating neck trauma. All 10 injuries in 118 patients were identified. Wood et al.98 found that esophagography alone was 100% sensitive and 96% specific in 225 patients. Ngakane et al.99 reviewed 109 patients with penetrating neck trauma. All patients with gunshot wounds underwent esophagography, whereas patients with stab wounds were only studied if they had pain with swallowing. Twenty-nine studies were performed and four injuries were identified. All were observed without intervention. Repeat contrast studies demonstrated resolution of the injury.

In 23 patients with esophageal injuries, Armstrong et al.92 found that esophagography only identified 62% of the injuries whereas rigid esophagoscopy detected all injuries. Srinivasan et al.100 found reasonable accuracy with flexible endoscopy. In 55 patients, flexible endoscopy identified the only two injuries, but suggested an injury in four patients, resulting in four negative explorations, for an overall sensitivity of 100% and specificity of 92%.

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Value of the Physical Examination

Recommendations

  • Level I: No recommendations.
  • Level II: No recommendations.
  • Level III: Careful physical examination using protocols for serial examinations, including auscultation of the carotid arteries, is >95% sensitive for detecting arterial and aerodigestive tract injuries that require repair. Given the potential morbidity of missed injuries, clinicians should have a low threshold for obtaining imaging studies.
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Scientific Foundation

Early reports suggested that the physical examination is unreliable to rule out a vascular injury. McCormick and Burch101 found physical examination of neck and extremity injuries yielded a 20% false negative rate and a 42% false positive rate. Metzdorff and Lowe102 found an overall 80% accuracy of physical examination. Apffelstaedt and Muller103 found that clinical signs were absent in 30% of patients with positive neck explorations and in 58% of patients with negative neck explorations, supporting their approach of mandatory exploration.

More recently, Demetriades et al.104 studied 335 patients with penetrating neck injuries. Sixty patients underwent exploration for positive physical examination findings or a positive workup, whereas 269 asymptomatic patients were observed. Only two of the latter patients later required elective procedures. In a subsequent article, this group demonstrated that physical examination did not miss any major vascular or esophageal injuries that required intervention; though minor injuries were identified by angiography (1 of 8 required intervention) and esophagography. Using a selective approach based on careful and repeated physical examinations, Gerst et al.105 observed 58 asymptomatic patients without sequelae. Of the 52 patients who underwent prompt exploration based on physical examination, 17% did not have significant injuries. Similarly, Beitsch et al.106 found that only 1 of 71 asymptomatic patients had a vascular injury detected by angiography. Thus, in this patient population physical examination ruled out 99% of vascular injuries and the yield for angiography was 1.4%. Atteberry et al.107 found that if patients did not have physical examination findings of arterial injury (active bleeding, expanding hematoma or hematoma larger than 10 cm, a bruit or thrill, or a neurologic deficit), no vascular injuries were present based on angiography, duplex ultrasound, or clinical follow-up. They observed patients for at least 23 hours.

Conversely, Sekharan et al.108 found that only 2 of 30 patients who underwent exploration for hard signs of vascular injury did not have a significant injury. Twenty-three of 114 asymptomatic patients underwent angiography for proximity or involvement of another zone. Only one of these patients needed an operation. All 91 other patients with negative physical examinations were safely observed without imaging. Azuaje et al.109 found that 68% of patients with positive physical examination had a positive angiogram. Of the 89 patients with negative physical examinations, only three had positive angiograms, but none needed operations. Overall, physical examinations had sensitivity of 93% and a negative predictive value of 97%. Both sensitivity and negative predictive value for injuries requiring operation were 100%.

A recent study by Mohammed et al.110 suggests caution in relying on physical examination alone to rule out vascular injuries secondary to gunshot wounds of the neck. Of 59 patients with gunshot wounds to any zone of the neck, 13 had positive physical findings suggesting a vascular injury, whereas 10 patients with negative physical findings were found to have injuries by angiography, giving physical examination a negative predictive value of 67%. The significance of these findings is difficult to determine, because they included all zones of the neck and did not define the severity of the injuries that were identified.

Subcutaneous emphysema or crepitance are physical findings suggestive of aerodigestive tract injuries that may require operative intervention. Goudy et al.111 reviewed the cases of 19 patients with emphysema or crepitance. Twenty-one percent had dysphagia, and 63% had stridor or hoarseness. Most underwent direct laryngoscopy and esophagoscopy. Patients without demonstrable injuries or small tears were successfully observed without exploration.

The best study, though small, that attempted to determine whether imaging adds to physical examination in the evaluation of patients with penetrating neck injuries was that by Gonzalez et al.112 Forty-two patients, who did not have obvious need for operation at admission, underwent soft tissue dynamic CT of the neck and esophagography before mandatory exploration. All tracheal and carotid injuries were identified by physical examination. Two of four esophageal injuries (both from stab wounds) were missed by both CT and esophagography. CT was better than physical examination for identifying venous injuries, but most of these did not require intervention.

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FUTURE DIRECTIONS

Selective management of penetrating injuries to zone II of the neck has become common for asymptomatic patients. The roles of physical examination, arteriography, duplex US, CT angiography, esophagography, and esophogoscopy remain unclear. At the moment, the single imaging modality that holds the greatest potential for ruling out vascular, tracheal, and esophageal injuries is CT angiography. Additional trials are needed to confirm this hypothesis. As the resolution of CT images improves, accuracy will surely increase. Rapid definitive imaging studies may allow early discharge of patients with neck injuries.

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Keywords:

Trauma; Neck; Carotid artery; Trachea; Esophagus

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