Basic considerations in the diagnosis and management of carotid artery injuries

Abstract

Most vascular injuries in the neck are the result of aggressive acts of violence, usually from knives or low-velocity bullets. These injuries are mainly confined to the wound tract, but when high-velocity weapons are used, there can be considerable damage from the blast effect. Blunt vascular trauma usually is more difficult to manage, and it can be overlooked because superificial evidence of injury to the neck is often absent? Moreover, patients involved in motor vehicle accidents or long falls may have head and spine injuries that pose other diagnostic problems. Patients being treated for blunt trauma usually have multiple injuries and often require several diagnostic tests. In the evaluation of patients with penetrating cervical trauma it is helpful to divide the neck into three zones, as described by Monson et al.3 Zone I extends from 1 cm above the clavicle down to include the base of the neck and the thoracic outlet, zone II is from 1 cm above the clavicle to the angle of the mandible, and zone III from the angle of the mandible to the base of the skull. Although important neurovascular structures traverse all three zones, their relationships to each other and ease of exposure vary in each zone; occasionally these differences require specialized maneuvers. It has been my practice to recommend surgical exploration of all penetrating wounds of the anterior triangles of the neck that pierce the platysma muscle, even when patients do not have an expanding hematoma. This remains controversial, and in the absence of specific identification of a major injury, some surgeons will defer surgery for observation and diagnostic evaluation. 4 Various tests can be performed, hopefully to exclude injury to the neurovascular structures or to the aerodigestive tract. In patients who show evidence of penetration of the esophagus (subcutaneous air or drainage) operation is required. Endoscopy and contrast studies to rule out penetra-