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Zone 3 Vascular Injury
Patients who are in profound shock or who are exsanguinating
from the neck wound require immediate haemorrhage control.
In Zone 3 injuries significant haemorrhage is most likely
to stem from injuries to branches of the external carotid
artery. These can be very difficult to control, and
may require dislocation or osteomotomy of the mandible
to achieve access. Where possible therefore, angiography
and embolisation is the modality of choice for delineating
and controlling the vascular injury, even in the haemodynamically
unstable patient. Where angiography is not available,
surgical intervention will be necessary.
Patients with an evolving stroke will
also require immediate exploration for internal carotid
artery injury. Otherwise non-operative management is
as for Zone 2 injuries. In the absence of hard signs
of vascular injury, the patient may be observed in a
critical care area.
Vertebral Artery
Vertebral artery injuries are more difficult to diagnose
and treat. Stab wounds to the posterior neck that are
bleeding extensively are likely to involve the vertebral
artery. There may be evidence of a hemi-cord (Brown-Sequard)
lesion on neurological examination. Many vertebral injuries
are asymptomatic and require no intervention - these
can be managed non-operatively. Exsanguination is usually
best controlled by angiography and embolisation, although
back bleeding from the basilar artery may continue.
There is also the potential for distal embolisation,
and the efficacy of the dual-balloon angiographic technique
has not been fully assessed. Operative control of the
vertebral artery as it courses through the vertebral
foramina can be exceedingly difficult.
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