Management by Zones

Zone I: sternal notch to cricoid cartilage

• high risk of injury to great vessels, trachea, and lungs

• difficult region for exposure and control

• Management: arteriography of arch, great vessels, carotids, and ver-tebrals (may also be used for balloon occlusion or temporary preop-erative control); esophagram with esophagoscopy, direct laryn-goscopy, and bronchoscopy

Zone II: cricoid cartilage to angle of mandible

• high risk of injury to carotid sheath (carotid artery, internal jugular vein) and aerodigestive system

• more easily accessible and more easy to control

• Management

1. Mandatory Surgical Exploration: gunshot wounds that cross midline, obvious serious injury (stridor, active hemorrhage, absent carotid pulse), active bleeding, air bubbling through wound, arteriography not available, intoxicated patient

2. Elective Surgical Exploration: more accurate than diagnostic tests, up to 50—70% of elective neck explorations are negative

3. Selective Management: arteriography, esophagram with esophagoscopy, direct laryngoscopy, and bronchoscopy

Zone III: angle of mandible to base of skull

• high risk of injury to distal carotid artery, parotid gland, and pharynx

• difficult region for exposure and control

• Management: arteriography (balloon occlusion), esophagram with esophagoscopy and direct laryngoscopy

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