Bleeding neck with stridor — balloon, signs, CTA boundary, carotid repair and the gullet that needs scoping

Examiner route

• Unstable split: active bleeding with expanding haematoma, stridor, and shock goes straight to theatre — patients whose condition is unstable undergo immediate operative exploration, with no international consensus to hide behind.^[33]
• Balloon bridge: compress then Foley — delayed failure 7% against 26% with pressure, mortality 5% against 23% in combat bleeders — then blood and theatre, with 6 of 8 civilian unstable successes as the civilian anchor.^[30]
• Signs fence: hard signs are specific but insensitive (55.4% sensitive, 88.1% specific for major injury across 310 patients at 29.7% prevalence) — and in 232 vascular injuries 19% of hard-sign patients needed no operation — so hard selects but never compels blindly.^[9][8]
• No-zone frame: the neck is evaluated as a unit rather than by external zones, sparing negatives — because only 59.1% of internal injuries share the wound zone.^[10]
• CTA boundary: stable soft-sign disease earns CTA (89.5 to 100% sensitive); even stable hard-sign zone II disease earned CTA in 23 patients with 17 unnecessary explorations prevented at one false-negative haematoma — quoted as selection, not delay of the unstable.^[2][29]
• Carotid choice: repair or revascularize except the devastated comatose; ligation is 100% poor (5 deficits, 4 deaths in 9) against 30% with restoration — so restore flow, stent the inaccessible, ligate almost never.^[11][15]
• Gullet close: CTA alone is insufficient with 19% of oesophageal injuries missed — scope or swallow every concerning gullet, because delay drives sepsis.^[3]

Pass standard

Controls the unstable bleeder with balloon-to-theatre without imaging, fences hard signs with 55.4/88.1 accuracy and the 19% no-operation caveat, applies no-zone CTA selection to the stable by zone-discordance 59.1% and CTA 89.5 to 100% including the narrow stable-hard exception (17 prevented, one false-negative), restores rather than ligates the carotid, and scopes every concerning gullet after CTA.^{[30][9][8][1][10][2][29][11][15][3]}