A 25-year-old man sustains a stab wound to zone II of the neck (between the angle of the mandible and the clavicle) with a hard sign of injury: expanding haematoma and absent right radial pulse. According to the current management algorithm, what is the most appropriate next step?

• A Immediate surgical exploration without further investigation ✓
• B CT angiography is the investigation of choice even for hard signs in zone II
• C Duplex ultrasound followed by angiography
• D Observation and repeat examination at 2 hours

Explanation

Hard signs of vascular injury (expanding haematoma, active external haemorrhage, absent distal pulse, bruit/thrill) in zone II penetrating neck trauma mandate immediate surgical exploration without delay for imaging. Zone II (the middle third of the neck) is the most accessible zone surgically, making direct exploration both feasible and life-saving. Modern 'no-zone' management with CT angiography for all penetrating neck injuries has largely replaced the three-zone approach, but CT angiography is reserved for haemodynamically stable patients with soft signs (haematoma not expanding, minimal bleeding, neurological deficit). This patient's haemodynamic compromise and hard signs make immediate surgery the correct answer.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.