An analysis and review of 100 penetrating wounds of the neck in a single civilian hospital has been presented.
The mortality in the series was 11 per cent, or approximately the same incidence of death reported for neck wounds from all of the great wars beginning with the Civil War. Civilian neck injuries, both in respect to the extent of damage and the time of therapy, are of a favorable type compared to war wounds. Yet the mortality rate in the present series fails to indicate that any comparative reduction in mortality has been obtained in the past 100 years, despite the greater amenability of civilian wounds to early definitive surgery. Every death in the present series, other than those due to associated injury, may be shown to be due to either an inordinate delay in surgery or inadequacy of surgical exploration. The devious paths which penetrating missiles into the neck may take, the variability of hemorrhage or associated signs seem only to offer the surgeon a false sense of security as to the true extent of damage in the neck. For these reasons it appears safe to conclude that the only certain method of determining the true extent of injury beneath the platysma is by early exploratory cervicotomy. In this respect the platysma in the neck may be compared to peritoneum of the abdomen in that the extent of injury when there is penetration of the latter can only be determined by exploratory laparotomy. This thesis is further attested to by the fact that there were only four instances of negative exploration in the eighty-three cases which were subjected to exploratory cervicotomy. In addition the mortality rate in those instances where exploration was performed was 6 per cent, compared to a death rate of 35 per cent when surgery was deferred or omitted. Table VIIITable VIII. Penetrating Wounds of the Neck Table VIII Summary of Deaths due to Penetrating Wounds of the Neck
| Patient | Age (yr.), Race and Sex | Type of Injury | Neck Injury | Time of Death | Other Injury | Remarks |
| L. L. | 19, N, M | Gunshot wound | Perforation of esophagus and larynx | 11 hr. | Transection of cord C6 | No surgery performed: hematcmesis, pulmonary obstruction; death; autopsy performed |
| A. M. | 52, W, M | Gunshot wound | Perforation of larynx; diffuse thyroid hemorrhage | 36 hr. | Penetration of abdomen (negative exploration), fractured mandible | Neck not explored: laparotomy and delayed tracheotomy; shock, pulmonary dysfunction, Cheyne-Stokes respiration; death; autopsy performed |
| E. M. | 25, N, M | Gunshot wound | Ilematoma in neck | . | Subarachnoid hemorrhage, laceration of brain | No surgery performed: patient comatose; Cheyne-Stokes respiration; death; autopsy performed |
| C. B. | 65, W, M | Laceration | External carotid artery, external jugular vein | 13 days | Fractured skull, retroperitoneal hemorrhage, subarachnoid hemorrhage, cerebellar hemorrhage and fractured pelvis | Shock, then restoration; cardiac failure, central nervous system signs; sudden death; autopsy performed |
| E. J. | 38, N, F | Gunshot wound | Penetrating wound; no apparent injury | 43 days | Transaction of cord C7, quadriplegia | Apparently no complications from neck injury (other than neurologic); sepsis, hypotension; death; no autopsy performed |
| J. T. | 23, N, M | Stab | Subclavian artery, vertebral artery | 8 days | None | Inadequate exploration: massive hemorrhage 104 hr. after admission; branch of subclavian artery ligated; massive hemorrhage; death; autopsy performed |
| A. V. | 35, N, M | Stab | Internal carotid | 13 days | None | Inadequate exploration: admitted to emergency room; pressure stopped bleeding; patient transfused; recurrent hemorrhage and shock; vessel ligated in emergency room; Cheyne-Stokes respiration; wound bled for 4 days; tracheotomy; death; no autopsy performed |
| C. D. | 29, N, F | Gunshot wound | Penetrating wound, injury unknown | 17 days | Cord injury to C7 with paraplegia; left hemothorax; penetrating wound to abdomen (exploration negative) | Neck not explored: paraplegia; fever, anemia, neck swelling, hemothorax; death; no autopsy performed |
| C. M. | 22, N, M | Gunshot wound | Trachea, right common carotid, right jugular vein | 50 days | None | Inadequate and delayed exploration; 1st admission — tracheotomy (no neck exploration); 1st postoperative day: bruit, base of neck; arteriovenous fistula. 2nd admission 4 wk. later — arteriovenous fistula (carotid artery and jugular vein repaired); 3rd postoperative day: hematorna; wound evacuated. 12th postoperative day: hemorrhage and shock; operation; pressure applied to site. 14th postoperative day: at operation, carotid artery and jugular vein ligated; patient critical. 24th postoperative day: hemorrhage; thoracotomy performed; subclavian and inominate arteries ligated. 33rd postoperative day; hemorrhage and death; autopsy performed |
| E. S. | 33, N, M | Gunshot wound | Subclavian artery, innominate vein | 8 days | None | Delayed surgery; observed for 8 days; thoracotomy performed; massive hemorrhage after lung separated from mediastinum; immediate death |
| H. C. | 48, N, M | Gunshot wound | Left subclavian vein | 5hr. | Left hemothorax | Thoracotomy; cardiac arrest during operation; death |
The principles of therapy for the management of penetrating neck wounds consist of adequate preoperative resuscitative measures, followed by immediate surgical exploration and definitive surgery. Whole blood transfusions, provision for an adequate airway and the emergency control of hemorrhage are imperative.
While a few minor wounds in cooperative patients may be explored under local anesthesia, general anesthesia with tracheal intubation is a prerequisite for surgical exploration. The wide surgical exposure necessary in many instances plus the reflex complications attending manipulations about the neck require obtundation of visceral reflexes by adequate atropinization and general anesthesia. In the present series local anesthesia was employed in twenty instances. The remainder of the cases were anesthetized with gas-oxygen-ether via endotracheal tube or tracheotomy.
The most common complications in the series were hemorrhage, sepsis or pulmonary dysfunction.
These complications may be reduced to a minimum by early definitive surgery, provision for an adequate airway, the restoration of normal respiratory mechanics, and adequate wound débridement and drainage.
Injuries to the carotid, subclavian and vertebral arteries deserve special consideration in therapy. Lacerations of major vessels by a knife or sharp instrument may often be treated by repair or axial anastomosis. Gunshot injuries, however, require wide débridement of the injured vessel which often results in inadequate length for anastomosis. While the restoration of continuity by prosthesis under these circumstances is desirable, it is not always mandatory and may be unwise in the presence of extensive contiguous injury.
The ill effects of prolonged respiratory obstruction, even if relieved by delayed tracheotomy, are often irreversible. Asphyxia, pulmonary edema and atelectasis are preventable complications if tracheotomy is performed on slight indication of impairment of airway. The maintenance of adequate tracheobronchial toilet following tracheotomy is an important adjunct to therapy.
The incidence of sepsis and wound infection is correlated with the type and extent of injury. Shotgun injury may be associated with extensive destruction of skin and much tissue injury while single missile bullets result in a comparative lesser degree of necrosis. Knife wounds usually result in little or no necrosis of tissue. Adequate débridement of all devitalized fragments including vascular, esophageal and tracheal tissues should be performed. Wound drainage is desirable as a routine measure. Antibiotics should be employed in all instances except in cases with minimal injury due to a clean knife wound.
