Analysis of 203 Patients with Penetrating Neck Injuries

Surgical management of transcervical gunshot injury presented with CSF leak and progressive left upper extremity paresis: a case report and literature review

INTRODUCTION

Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality.

RESEARCH QUESTION

There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients.

METHODS AND MATERIALS

An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness.

RESULTS

The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up.

CONCLUSION

Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects.

'No zone' approach in the management of penetrating neck injuries - an Australian Tertiary Trauma Centre experience

PURPOSE

Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone-based approach to a 'no zone' algorithm, resulting in reduced non-therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a 'no zone' approach could be safely implemented in this population, as has been demonstrated internationally.

METHODOLOGY

This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT-A) use and operative intervention. Patients were examined based on zone of injury and presenting signs - 'hard', 'soft' or 'asymptomatic'. Major outcomes were CT-A usage, positive CT-A correlation with therapeutic neck explorations and negative neck exploration rates.

RESULTS

This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT-A utilization increased from 55% to 94.1%, with positive CT-As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non-therapeutic neck explorations.

CONCLUSION

Our data suggests similarities with results from around the world, demonstrating that the 'no zone' approach should be considered when managing PNIs, but with clinician discretion in individual cases.

How Can We Manage Penetrating Neck Injury with Blunt Carotid Injury and Spinal Injury: Case Report and Review of Literature

The Neck is a cylindrical structure containing vital neurovascular and visceral structures tightly packed in a relatively small volume. Mortality rate increases when there is an injury to vascular structures especially the carotid artery, surrounded by other vital neurovascular structures; injuring the neck leads to devastating morbidity when compared to other injuries. With increased awareness of screening techniques and improved detection rates, there is an urge in opting for selective neck exploration and initial aggressive antithrombotic therapy for blunt carotid artery injuries. Here we report a case of a 20-year-old male, with a lacerated injury of the right side of the neck causing transection of the right internal jugular vein, grade 4 (Denver classification) blunt carotid injury, along with cervical vertebral fractures without neurological deficits. The patient underwent emergency surgical neck wound exploration, flush ligation of transacted Right Internal Jugular Vein, and conservative management for blunt carotid artery injury using anti platelets (Aspirin and Clopidogrel) avoiding any immediate neurological deficits. Whenever lacerated neck wounds are evaluated, the chance of blunt injury to the carotid is to be borne in mind and such an injury can be managed with double antiplatelet therapy, if there are no demonstrable neurological deficits.

5-Year management and outcomes of penetrating neck injury in a trauma center. Penetrating neck injury

BACKGROUND

Penetrating neck injuries represent 5-10% of all traumatic injuries, these bring with them a high rate of morbidity and mortality due to vital structures that could be injured in this area. The aim of this study was to determine the epidemiological and clinical characteristics of penetrating neck injuries.

METHODS

This was a retrospective, unicentric and descriptive study that included all patients who underwent neck exploration surgery.

RESULTS

A total of 70 neck exploration cases were reviewed, 34 (49%) didn't had any injury. Thirty (43%) had at least one hard sign, 42 (60%) patients showed at least one soft sign. Statistical analysis showed only surgical time (252±199.5 vs. 155±76.4; p=0.020) and transfusions (1.87±3 vs. 0.4±0.856; p=0.013) were statistically significant. We report a mortality of 2 (3%) patients.

CONCLUSIONS

Our prevalence of neck surgical exploration without vascular injury was slightly higher (49% vs. 40%) than literature. We highlight the importance of not performing neck explorations in all patients who present a penetrating injury. We did not obtain differences between groups for hard signs and soft signs. We were not able to identify whether or not there would be an injury based on clinical characteristics. Imaging studies should be performed to avoid unnecessary neck explorations; however, depending on the clinical scenario some surgery cannot be avoided.

Trauma cervical penetrante: experiencia de un hospital de enseñanza en México

Introducción. El trauma cervical penetrante es una entidad poco frecuente, con tendencia al alza, de considerable morbimortalidad. Es fundamental conocer su manejo por cirujanos en entrenamiento, quienes en su mayoría son comúnmente los proveedores del tratamiento en las áreas de urgencias. El objetivo de este estudio fue demostrar la experiencia de un centro de trauma en México en el tratamiento de trauma cervical penetrante administrado por cirujanos en entrenamiento. Métodos. Estudio retrospectivo de pacientes con diagnóstico de trauma cervical penetrante sometidos a exploración cervical entre los años 2014 y 2019. Se identificaron 110 expedientes, se excluyeron 26 por falta de datos indispensables para la investigación y se analizaron los datos de 84 pacientes. Resultados. El 96,4 % de los pacientes fueron hombres, la mayoría entre 16 y 50 años (83,3 %) y la zona anatómica II fue la más comúnmente lesionada (65,4 %). Las etiologías más frecuentes fueron heridas por arma cortopunzante (67,9 %) y heridas por proyectil de arma de fuego (25 %). El 95 % de los procedimientos fueron realizados por residentes de cuarto y quinto año. La mediana de días de estancia hospitalaria fue de 2 días. La incidencia de complicaciones fue de 9,5 % y la mortalidad de 1,2 %. Conclusiones. Los cirujanos generales en etapa de formación entrenados en centros de trauma tienen la capacidad de tratar de forma óptima el trauma cervical penetrante sin modificación de las tasas de morbimortalidad descritas en la literatura internacional.

Penetrating injury with an arrow impacted in the neck in rural Tanzania, a case report

Introduction and importance

Penetrating neck injuries refer to neck injuries that penetrate through the platysma layer which can cause life-threatening injuries to the aerodigestive and neurovascular systems. Currently penetrating neck injuries are mainly due to modern firearms however penetrating neck injuries due to arrows are still seen, although rare, in rural areas among developing countries. Management depends on hemodynamic stability, signs of structural damage and zone of neck involved.

Case presentation

19-year-old male presenting with a penetrating arrow impacted in his neck following an attack by cattle raiders who was otherwise stable of presentation. Underwent preoperative imaging with removal of the arrow under general anaesthesia via surgical exploration.

Clinical discussion

We concur with the recommendation to first obtain adequate imaging to establish degree of injury as well as for operative planning. Removal of impacted arrow should not be carried out blindly but rather in a controlled environment under general anaesthesia via surgical exploration.

Conclusion

Penetrative arrow injuries to the neck are an archaic problem that can be dealt with via modern surgical principles towards penetrating neck injuries. Unstable patients warrant emergent exploration however stable patients can first be worked up appropriately to ascertain degree of injury. Impacted arrows can then be removed safely under general anaesthesia rather than risk further injury to critical structures via blind removal.

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Penetrating neck injury by an impacted arrow in rural countryside

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Application of surgical principles in penetrating neck injury due to an arrow

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Assessing relevant vascular anatomy via ultrasound due to financial constraints

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Successful surgical exploration and safe removal without postoperative complications

Civilian Penetrating Neck Trauma at a Level I Trauma Centre: A Five-Year Retrospective Case Note Review

OBJECTIVES

To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings, and radiological reports.

DESIGN

Retrospective case note review SETTING: UK level I trauma centre April 2012-November 2017 PARTICIPANTS: 310 cases of PNT were drawn from electronic patient records. Data was extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes.

MAIN OUTCOME MEASURES

Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration.

RESULTS

271 (87.4%) male and 39 (13.6%) female patients with a mean age 36 years (16 - 87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%) and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r=0.89, p=0.045 between hard signs plus positive radiology findings and internal injury on neck exploration.

CONCLUSIONS

Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach

Background

Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a ‘no‐zone’ approach to PNI is valid.

Methods

Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared.

Results

In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination.

Conclusion

An approach to PNI based on zones is questionable, and this study supports a no‐zone approach based on imaging guided by clinical examination.

Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test

Background

There are many high-volume trauma centers in limited resource environments where a thorough clinical examination of patients may contribute to a more economical, accurate, and widely applicable method of determining the proper management of patients with penetrating neck injuries. The purpose of this study was to validate thorough physical examination as a reliable diagnostic tool in these patients.

Methods

We performed an observational retrospective study of a diagnostic accuracy test where we compared clinical findings (symptoms and soft signs on admission of the patient) with the definitive findings according to the gold standard test for each particular situation (selective studies, clinical observation and surgical exploration). The study was conducted at Hospital Occidente Kennedy (HOK) between August 2009 and June 2010.

Results

The sample consisted of the clinical records of 207 (n = 207) patients who went to the emergency room for penetrating neck wounds at Hospital Occidente Kennedy (HOK). Of the total sample, 36.2% (n = 75) of patients were considered “asymptomatic” as they didn’t present with any soft signs of injury. Vascular soft signs were present in 57% (n = 118) of the patients, soft signs of the airway and the upper gastrointestinal tract were present in 15.9% (n = 33) and 21.3% (n = 44) of the patients respectively. The sensitivity and negative predictive value (NPV) of any soft sign to determine injuries which require surgical repair was 97.4% [CI] [86.5–99.5%] and 98.7% [CI] [92.8–99.8%] respectively, with a range of confidence [CI] of 95%.

Conclusions

Our study’s main findings suggest that patients with neck injuries and no vascular, airway, or gastrointestinal soft sign can be safely managed with a conservative approach. It is important to emphasize the value of the clinical examination since there are many contexts in the modern world where a considerable amount of the population is afflicted by neck trauma and treated under conditions where technological resources are limited.

Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem

OBJECTIVES

Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective non-operative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines.

METHODS

Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case.

RESULTS

Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n = 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n = 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n = 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived.

CONCLUSIONS

This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

The Tsukui (Japan) Yamayuri-en Facility Stabbing Mass-Casualty Incident

INTRODUCTION

In July 2016, a mass-casualty stabbing attack took place at a facility for disabled persons located in Sagamihara City (Kanagawa Prefecture, Japan). The attack resulted in 45 casualties, including 19 deaths. The study hospital dispatched physicians to the field and admitted multiple casualties. This report aimed to review the physicians' experiences and to provide insights for the formulation of response measures for similar incidents in the future.

REPORT

This incident involved 30 emergency teams and 12 fire department teams, including those from neighboring fire departments. Five physicians from three medical institutions, including the study hospital, entered the field. The Simple Triage and Rapid Treatment (START) method was used on the field. The final field triage category count was: 20 red, four yellow, two green, and 19 black tags. All the casualties (n = 26) except for the 19 black tag casualties were transported to one of six neighboring medical institutions.The median age of the transported casualties was 41 years (interquartile range [IQR] = 35.5 - 42.0). Three casualties (21.4%) were in hemorrhagic shock on arrival at the hospital. Twelve patients had multiple cervical stab wounds (median four wounds; IQR = 3.75 - 6.0). A total of 91.7% of these stab wounds were in mid-neck Zone II region. Of the 12 patients with cervical stab wounds, four (33.3%) required emergency surgery, and the rest were sutured on an out-patient basis. One patient had already been sutured on the field. All patients requiring emergency surgery had deep wounds, including those of the carotid vein, thyroid gland, nerves, and the trachea. Eight of the casualties were hospitalized at the study institution. Five of them were admitted to the intensive care unit. There were no deaths among the casualties transported to the hospitals.

CONCLUSION

Regional core disaster medical hospitals must take on a central role, particularly in the case of local disasters. Horizontal communication and interactions should be reinforced by devising protocols and conducting joint training for effective inter-department collaborations on the field.Maruhashi, T, Takeuchi, I, Hattori, J, Kataoka, Y, Asari, Y. The Tsukui (Japan) Yamayuri-en facility stabbing mass-casualty incident. Prehosp Disaster Med. 2019;34(2):203-208.

Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma: A single-center review of 86 cases

BACKGROUND

This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM).

METHODS

This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation.

RESULTS

Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19-8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13-6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks.

CONCLUSION

Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration.

LEVEL OF EVIDENCE

Clinical Management Study, Level V evidence.

Penetrating neck trauma caused by a rebar: A case report

RATIONALE

Penetrating neck trauma has a mortality of 3% to 6% and is associated with serious complications, mainly due to the high density of vital structures in this area and the lack of corresponding protection from bone.

PATIENT CONCERNS

A 55-year-old man who suffered neck trauma involving the parotid gland, caused by a rebar, after suffering a fall from the second floor of a building.

DIAGNOSES

Penetrating neck trauma.

INTERVENTIONS

The patient underwent a neck exploration under general anesthesia in the emergency operating room and tracheotomy was performed prophylactically.

OUTCOMES

The foreign object was ultimately removed successfully with no complications.

LESSONS

We concluded that computed tomography (CT) and three-dimensional reconstruction of the CT images can be a viable method to exclude macrovascular injury for patients who are in an emergency condition and are not eligible for computed tomography angiography (CTA). A chest tube could be used as an option for the removal of foreign bodies in the case of sharp or rough objects (such as spiral foreign bodies), when fully exposing the foreign body and its track.

Forty hours with a traumatic carotid transection: A diagnostic caveat and review of the contemporary management of penetrating neck trauma

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup.

Computed Tomography Angiography is the Definitive Vascular Imaging Modality for Penetrating Neck Injury: A South African Experience

Background and Aims:

Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa.

Materials and Methods:

A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included.

Results:

A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating “true arterial injury” was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography.

Conclusion:

Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.

"No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations

BACKGROUND

The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a "no zone" approach.

METHODS

An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries).

RESULTS

A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs (P = 0.23) or soft signs (P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE.

CONCLUSIONS

Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking.

Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre

BACKGROUND

There has been a shift towards conservative management of penetrating neck trauma in selected patients.

METHODS

A retrospective case note review of the management of penetrating neck trauma (2007-2013) was undertaken at our large teaching hospital and compared against best-evidenced practice.

RESULTS

Sixty-three patients were admitted over six years. The incidence of penetrating neck trauma is reducing, contrary to our belief. Most cases were knife inflicted (33 out of 63), and of these most were attempted suicide. There was a high rate of negative findings for neck explorations under general anaesthesia (18 out of 22). Only nine cases had justification for general anaesthesia exploration according to best practice.

CONCLUSION

The rate of neck explorations under general anaesthesia has dramatically fallen, in line with best practice. The need for operative intervention in patients with penetration of the aerodigestive tract or a major vascular injury should be based on clinical features, and these have been shown to be reliable indicators prior to open exploration.

Safety in selective surgical exploration in penetrating neck trauma

BACKGROUND

Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality.

METHODS

A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims.

RESULTS

Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies.

CONCLUSION

Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.

A comparative audit of gunshot wounds and stab wounds to the neck in a South African metropolitan trauma service

Introduction The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI). Methods A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications. Results There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a 'significant cervical injury' was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients. Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%). Conclusions Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be managed conservatively with a good outcome. Imaging should be performed for all GSWs to the neck.

An audit of penetrating neck injuries in a South African trauma service

INTRODUCTION

This study reviews and validates the practice of selective non-operative management (SNOM) of penetrating neck injury (PNI) in a South African trauma service and reviews the impact new imaging modalities have had on the management of this injury.

METHODOLOGY

This study was performed within the Pietermaritzburg Metropolitan Trauma Service, in the city of Pietermaritzburg, Kwazulu-Natal, South Africa. A prospectively maintained trauma registry was retrospectively interrogated. All patients with PNI treated over a 46-month period were included within the study.

RESULTS

A total of 510 patients were included in the study. There were 452 stab wounds (SW) and 58 gunshot wounds (GSW). A total of 202 (40%) patients sustained isolated PNI, the remaining 308 (60%) patients sustained trauma to at least one additional anatomical region. An airway injury was identified in 29 (6%) patients; a pharyngo-oesophageal injury in 41 (8%) patients and a vascular injury in 86 (17%) patients. Associated injuries included three penetrating cardiac injuries (PCI) and 146 patients with haemo-pneumothoraces. Of the total cohort, 387 patients (76%) underwent CT Angiography (CTA), of which 70 (18%) demonstrated a vascular injury. Formal catheter directed angiogram (CDA) was performed on 16 patients with positive CTA but confirmed injury in only half of these patients. Of 212 patients (42%) who underwent water-soluble contrast swallow (WS-swallow), an injury was demonstrated in 29 (14%) cases. A total of 401 (79%) patients were successfully managed conservatively for PNI and 109 (21%) surgically or by endovascular intervention. Only five (1.2%) patients failed a trial of SNOM and required surgery. The in-hospital mortality rate was 2%. No deaths could be attributed to a failure of SNOM.

CONCLUSION

SNOM of PNI is a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity, is associated with a low yield. CTA has a significant false positive rate and good clinical assessment remains the cornerstone of management.

A retrospective study of computed tomography angiography versus digital subtraction angiography in penetrating neck trauma at Groote Schuur Hospital, South Africa

Background: Penetrating neck trauma is commonly encountered in South African trauma units, and is associated with high mortality and morbidity rates. The imaging protocol for stable patients with penetrating neck trauma remains controversial. There is only sparse data validating the use of computed tomography angiography (CTA) in the evaluation of penetrating neck trauma in South Africa.Objectives: To assess the sensitivity and specificity of CTA versus digital subtraction angiography (DSA) in detecting arterial injury and secondarily evaluate the ability of CT to assess non-arterial injury.Method: Using hospital and radiology databases, 23 patients were identified who had undergone both CTA and DSA for penetrating neck trauma. The data was retrospectively anonymised and randomised. A radiologist experienced in the interpretation of both trauma CTA and DSA re-reported all the imaging and the findings were compared and analysed.Results: Twenty-four arterial injuries were detected. The sensitivity of CTA for detecting arterial injury was 78% and the specificity 83%. The ability of CTA to delineate wound track and detect non-arterial visceral injury was also confirmed.Conclusion: CTA is an attractive initial diagnostic investigation that, along with clinical evaluation, effectively guides further investigation and intervention. It is important for the radiologist to understand the limitations of CTA and have a low threshold for DSA in equivocal cases.

Management of penetrating neck injuries

BACKGROUND

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

METHODS

Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations.

RESULTS

Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected.

CONCLUSION

FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only.

An evidence based review of the assessment and management of penetrating neck trauma

BACKGROUND

Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format.

TYPE OF REVIEW

Structured, non-systematic review of recent medical literature.

SEARCH STRATEGY

An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day.

EVALUATION METHOD

Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance.

RESULTS

147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation.

CONCLUSIONS

Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.

Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients

BACKGROUND

The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients.

METHODS

This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified.

RESULTS

A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16).

CONCLUSION

The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.

Conservative management of laryngeal perforation in a rural setting: case report and review of the literature on penetrating neck injuries

Penetrating neck injuries (PNIs) are infrequent but can result in significant morbidity and mortality. Although surgical management of unstable patients with penetrating neck trauma is the standard of care, management of stable patients remains controversial owing to the possibility of occult injuries. Recent studies suggest that physical examination and ancillary imaging may be sufficiently accurate to diagnose or rule out surgically significant injuries in PNI. We report a patient with a laryngeal perforation who was managed conservatively in a rural hospital without complications and review the literature pertinent to cases of this nature.

Two days with a broken knife blade in the neck--an interesting case of Horner's syndrome

A 25-year-old man presented to the Emergency department in a rural South African hospital after a left, submental neck stab with a knife. Examination was deemed unremarkable, and the patient was discharged, but re-attended 2 days later complaining of a painful, swollen neck. Further examination identified Horner's syndrome, and further investigation revealed that the blade of the knife had remained in the patient's neck. This was successfully removed in theatre. This case illustrates the importance of careful history, examination and diagnostic imaging in the management of penetrating neck injuries. Horner's syndrome can be easily missed in a busy Emergency department and may indicate life-threatening pathology in the context of neck trauma. The difficulties in assessing and managing this type of injury are discussed.

Experienced Airway Management in Laryngotracheal Injuries: Series of Cases, Survey and Review of Literature

Definitive airway control of penetrating laryngotracheal injury can be an extremely difficult challenge for the emergency physician. We report three serious cases of penetrating neck trauma with laryngeal injury that were managed successfully using different techniques of airway control in the Emergency Department (ED) of Hamad General Hospital during the three years from January 2006 through December 2008. Individualized assessment, identification of type of injury and familiarity with airway control techniques and the available options assure timely, safe and proper airway control in such injuries. Choice of technique in penetrating laryngotracheal injury is multifactorial and depends upon case presentation, physician preference, skill, and clinical constraints. The incidence of neck injury during this period was lower than in other reports; being 0.07 % of total trauma cases, while the incidence of penetrating neck injuries represented 17.6% of total neck injuries with no deaths. Implications Statement: Familiarity and availability of variant airway management techniques and variant surgical interventions in penetrating laryngotracheal injuries, improve outcome and reduce mortality.