Review Question - QID 106350

This patient has sustained a penetrating neck injury (PNI) to zone III (above the angle of the mandible). Given his stable vitals, exam, and ability to protect his airway, this should be managed with CT angiography.

There are 3 defined zones with PNIs:

1. Above the angle of the mandible (zone III)
2. Between the angle of the mandible and the cricoid cartilage (zone II)
3. Below the cricoid cartilage (zone I)

Classically, zone I and III require endoscopy and angiography as surgical exploration of these zones surgically is challenging. Zone II is classically managed with surgical exploration. Another more modern approach to PNIs is to use a no-zone approach. This approach is based on patient stability and the presence of soft versus hard signs of injury regardless of the location of the injury. An appropriate imaging modality using the no-zone approach or the classic approach (for a zone III injury) is CT angiography.

Incorrect Answers:
Answer 1: Arteriography is an accurate test when imaging the vessels of the head and neck; however, this method of imaging has largely been replaced by CT angiography.

Answer 3: Intubation would not be indicated in this patient who is protecting his airway. If he was failing to oxygenate/ventilate, could not protect his airway, or had impending airway loss then intubation would be appropriate.

Answer 4: Observation and blood pressure monitoring are inappropriate as a vascular/structural injury should be further characterized by imaging.

Answer 5: Surgical exploration is not necessarily indicated given the absence of dire signs on exam and the fact that zone III is injured.

Bullet Summary:
Zone III injuries per the no-zone and the zone approach warrant initial vascular imaging with a CT angiogram in a stable patient.