Penetrating Neck Trauma: The No-Zone Approach in Civilian and Combat Settings

Penetrating neck trauma forces the surgeon to make high-stakes decisions quickly — and in an austere environment, the vascular or head-and-neck surgeon you would normally call may simply be you.

This lecture explains how management has shifted from traditional zone-based exploration toward the modern no-zone approach. It covers the role of hard signs and hemodynamic instability, CT angiography, reconstruction of the injury trajectory, and the surprisingly important value of a systematic bedside neck examination when advanced imaging is unavailable.

The discussion then moves into a real combat case involving a devastating carotid injury managed by a single surgeon at a small forward surgical team. Through the case, the speaker examines exposure and hemorrhage-control techniques, temporary shunting versus ligation or reconstruction, graft selection, neurologic assessment, wound management, and how evacuation time can completely change the safest strategy.

The Q&A adds an especially relevant perspective: Ukrainian and US experience with carotid shunts, stroke risk during prolonged evacuation, primary repair, wound closure in contaminated combat injuries, and the limits of endovascular treatment. It is a focused lesson in adapting vascular trauma principles to the resources, expertise, and transport realities actually available.