Some situations require a definitive maneuver prior to formal exploration. Tracheal injuries require definitive airway control. Laryngoscopic or fiber-optic endotracheal intubation is often possible and worth attempting. Large injuries allow direct intubation through the wound which is an acceptable temporary airway. Otherwise, emergency cricothyroidotomy is the quickest approach and may be left as a definitive airway without conversion to tracheostomy.

Bleeding is usually controllable with digital pressure. Subclavian injuries can be difficult to compress. Place a Foley catheter into the wound, inflate it, and pull against the clavicle for tamponade.

Several steps can help optimize surgical approach. Obviously, the cervical collar is removed. It is unnecessary to follow cervical spine precautions in penetrating neck trauma since the probability of an unstable cervical spine with a penetrating mechanism is exceedingly small, and suboptimal positioning can seriously impair the ease of access to the neck. Place a transversely oriented shoulder roll to obtain some neck extension. Turn the patient’s head away from the side of initial exploration. Prep both sides of the neck starting at the mastoid process. Leave the tips of the pinnae and angles of the mandible exposed. Prep the sternum into the field for possible extension of the neck incision into a sternotomy. Prep one leg for possible vein graft. Finally, if you are uncertain about the exact trajectory of a missile, consider prepping the abdomen as well. Make sure to ask to have the following equipment immediately available: vascular suture such as 5-0 Prolene, vascular clamps, vascular grafts and patches, a variety of balloon embolectomy catheters, and a sternal saw and sternal retractor. Request the anesthesiologist to place a large bore nasogastric (NG) tube.

The workhorse access is the anterior sternocleidomastoid (SCM) incision (Fig. 30.2). Make a generous incision along the anterior border of the sternocleidomastoid. At the angle of the mandible, curve the incision slightly posteriorly to remain at least 2 cm from the mandible and thus avoid injury to the marginal mandibular branch of the facial nerve. The platysma is divided, and the dissection is continued anterior to the SCM. Look for the internal jugular (IJ) vein. The facial vein crosses the wound and empties into the IJ. Divide the facial vein or veins. It is also acceptable to divide the IJ as well, if there are other injuries, the patient is doing poorly, or the vessel is badly injured.