Mechanisms of penetrating injury can be categorized as stab, gunshot, shotgun, or miscellaneous sharp implements. All mechanisms have potential for causing serious injury. Seemingly innocuous wounds may involve multiple structures. Gunshot wounds cause damage both from the bullet itself and from the blast effect. In addition, the path of a bullet is unpredictable. Localizing a bullet will not delineate which structures it has traversed or disrupted. If the bullet has crossed the midline of the neck, however, there is a high probability of injury. Transcervical gunshot wounds are twice as likely to cause injuries to vital structures in the neck as are gunshot wounds that do not cross the midline.6 Damage caused by shotguns depends largely on weapon-victim range, and type of weapon and shot used. Multiple pellets scattered across all three zones of the neck characterize these wounds.7 Although the course of stab wounds is more limited than that of gunshot wounds, there is still clear potential for major injury.
Despite differences in mechanism, treatment principles are the same. Initial stabilization is always the primary concern. Once this is accomplished, attention is turned to examination of the wound itself. If the platysma muscle is clearly intact, local wound repair is all that is required. If the platysma has been violated it must be assumed that significant injury has occurred. Neck wounds must never be probed beneath the platysma in order to avoid disrupting hemostasis. The next priority is establishing wound location and determining which zones are involved. Vital structures at risk for injury can then be identified. Careful physical examination may reveal hard and soft signs of injury. A diagnostic plan, which will evaluate vulnerable structures, is then implemented.
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