Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVII: Wounds and Injuries of the Neck

Vascular Injuries

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

Injury of major neck or mediastinal vascular structures is often fatal. Venous injuries have the added risk of air embolism. Serious vascular injuries may be masked by the severe shock state in the patient with multiple injuries. These may become apparent only after resuscitation has begun. The severity of blood loss may be masked when neck wounds communicate with the pleural space (hemothorax). Suspicion of vascular injury requires early exploration. Anterior thoracotomy in the third interspace on the involved side permits immediate intrathoracic access to the great vessels. Bleeding sites can be controlled with direct pressure and packs while developing definitive exposure. Definitive exposure of this region is then provided by median sternotomy. This exposure also can be obtained by extending the neck incision into a full median sternotomy incision.

The following points regarding the management of vascular injuries are emphasized:

1. The mortality from uncontrolled hemorrhage is second only to asphyxiation in wounds to the neck. Airway control and hemostasis are, therefore, the initial steps.
2. Serious vascular injury often presents as a gradually enlarging hematoma, which can encroach upon the airway. Airway encroachment is produced by hematoma which expands within the triple-layered, closed, deep fascial compartments of the neck. The fascial arrangement also prevents outward expansion of extravasating blood, sometimes making the diagnosis of vascular injury difficult.
3. Penetrating wounds of the neck, because of the possibility of vascular injury, require definitive surgical exploration. Exploration should include the carotid and internal jugular systems. Should vascular repair be required, adequate exposure with proximal and distal control is the cardinal technical consideration in vascular surgery.
4. Lateral repair or end-to-end anastomosis after debridement of the injured wall of any artery is preferred. If this is not possible, an autogenous vein graft may be used to bridge an arterial defect. The use of an internal or external shunt to maintain cerebral circulation during repair is preferred. The importance of adequate oxygenation and maintenance of blood volume cannot be overemphasized.
5. The external carotid system may be ligated without morbidity. Ligation of the internal carotid artery may be the safest procedure for patients with an injury to this vessel when there is an already established neurological deficit.
6. Ligation of the internal jugular system is indicated when lateral repair is not possible.

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