Evaluation and management of penetrating wounds of the neck: the role of emergency angiography

Esophageal perforation: a delayed complication following traumatic spinal cord injury. Case report

Esophageal perforation is an uncommon but serious complication of penetrating injuries to the neck and chest. A case of delayed esophageal perforation in a patient with traumatic spinal cord injury is presented. The pathophysiology, diagnosis, and treatment of this potentially fatal complication are discussed.

A twelve-year survey of cervicothoracic vascular injuries

This study of a large series of victims of trauma to the cervicothoracic great vessels confirms the lethal potential of these injuries: more than half of victims of such injuries died. The optimal management of patients potentially harboring such vascular damage appears to include skilled prehospital resuscitation and rapid transport to a trauma center, a high index of diagnostic suspicion, a low threshold for the performance of contrast arteriography, aggressive surveillance for associated neurologic and aerodigestive tract injuries, and timely technical repair, including liberal indications for sternotomy or thoracotomy to assure vascular control.

Analysis of 18 recent cases of penetrating injuries to the common and internal carotid arteries

Penetrating injuries to the common and internal carotid artery carry the unique potential for irreversible neurologic damage, respiratory collapse, and exsanguination. This study analyzes a recent 4 year experience with 18 cases of penetrating injury to the carotid artery to identify the factors influencing surgical decision-making, perioperative complications, and mortality. Sixteen patients with acute respiratory distress required emergent airway intubation. Three patients in hemorrhagic shock were brought directly to the operating room; the remaining 15 underwent emergency carotid arteriography. Three patients with multiple intramediastinal vascular injuries exsanguinated on the operating table before hemorrhage could be controlled. There were no deaths or neurologic complications in the 14 surviving patients who had an operation on the carotid artery, including 2 patients treated by internal carotid artery ligation. Early control of the airway was the most common initial requirement in this group of patients. Judicious use of preoperative arteriography was thought to facilitate the operative approach in selected patients. A flexible surgical approach to the damaged carotid artery is essential based on the patient's hemodynamic status, degree of neurologic impairment, and nature and extent of arterial damage.

Diagnosis of penetrating cervical esophageal injuries

Arterial injuries pose the greatest early threat to the patient with penetrating neck trauma and esophageal injuries, the greatest late threat. Clinical evaluation reliably identifies 80 percent of esophageal injuries, which, in our opinion, is not adequate. In 118 minimally symptomatic or asymptomatic patients with penetrating neck trauma, the combination of esophagography with esophagoscopy identified all 10 esophageal injuries in 118 patients with penetrating neck trauma. These data suggest that patients with penetrating neck trauma and minimal clinical findings should be initially evaluated with arteriography and esophagography. If the results of arteriography or esophagography are positive, then neck exploration should be performed. If the results of esophagography are equivocal, then rigid esophagoscopy should be performed. If all test results are negative, then observation is justified.

Traumatic rupture of the cervical carotid arteries: an autopsy and histopathological study of 200 cases

Over the 19-month period November 7th, 1984 to June 11th, 1986, 200 consecutive autopsies were conducted on victims of motor vehicle accidents. In each case, both common carotid arteries and their respective internal and external branches up to 2 cm beyond the bifurcation were examined for evidence of contusion, partial tearing or rupture. All lacerations or disruptions were excised together with a segment of surrounding arterial tissue, and processed, sectioned and examined by conventional light microscopy for the presence and extent of arterial tears. Several findings emerged: (i) in nearly one-third of subjects there was some degree of arterial disruption; (ii) dual or even triple vessel involvement in both an ipsilateral and contralateral distribution occurred in 38.6% of the 57 subjects in whom traumatic arterial lesions were found; (iii) the large number of intimal disruptions encountered, 44.7% of which showed extension of the tear to the internal elastic lamina with further longitudinal continuation of the tear along the lamina without breaching it; (iv) tears along the laminar planes of the media occurred in 52.6% of the 57 subjects and was particularly apparent at sites of subsidiary vessel bifurcation; (v) compound intimo-medial tears occurred in almost two-thirds (63.2%) of the 57 subjects, highlighting the dual involvement of these layers of the arterial wall in traumatic lesions; (vi) the occurrence of adventitial contusions in 70.2% of the 57 subjects; (vii) the occurrence of complete vessel wall transection in more than one-quarter (26.3%) of the vessels with positive findings and involving nearly one-third (31.6%) of subjects, indicating perhaps the severity of the trauma to which the victims were exposed.

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck

Of 193 patients with penetrating wounds of the neck, 76 had only surgical exploration; 57 had only nonsurgical exploration including one or more of the following: arteriography, bronchoscopy, laryngoscopy, esophagoscopy, and contrast-swallow esophagogram; and 60 had both surgical and nonsurgical exploration. Eighty-six patients were wounded by gunshot, 108 by stabbing. Presenting signs and symptoms were an unreliable method of predicting presence or absence of injury. Overall negative rate of surgical exploration was 50% (54% of the stabbings and 45% of the gunshots). Accuracy of nonsurgical exploration was assessed by comparing to surgery. Arteriography was 100% accurate, a combination of bronchoscopy and laryngoscopy was 100% accurate, contrast-swallow esophagogram was 90% accurate, and esophagoscopy was 86% accurate. The literature was reviewed regarding the accuracy of nonsurgical as well as surgical exploration. The one complication attributed to nonsurgical exploration was a symptomatic anemia, while there were two wound infections resulting in increased length of stay associated with negative surgical exploration. Overall mortality rate was 5.6%. The average length of stay for nonsurgical exploration only was 2.8 days, for negative surgical exploration was 4.2 days, and for positive surgical exploration was 9.5 days. Financial cost of a negative surgical exploration was $3185, while for four-vessel cerebral arteriography with panendoscopy it was $3492. More studies need to be done, particularly concerning venography and esophagoscopy. However, considering the fact that surgical exploration should by no means be considered 100% accurate, the data in this study support the fact that arteriography with panendoscopy represents an equally safe and acceptable method of exploration of penetrating wounds of the neck for stable patients without specific signs and symptoms of injury and can be expected to result in a reduced number of negative surgical explorations and their associated morbidity as well as a reduced length of hospital stay, although at a slightly higher financial cost when compared to mandatory surgical exploration.

Penetrating neck trauma: consensus and controversies

Proper emergency evaluation and treatment of the victim of penetrating neck trauma requires a thorough knowledge of cervical anatomy and of the injuries that are likely to occur. Nonoperative studies supplement the physical examination in the evaluation of these patients, and may either assist in the operative approach or allow for safe observation of the patient. The debate concerning exploration and observation of penetrating neck wounds continues.

Selective emergency arteriography in cases of penetrating maxillofacial trauma

Selective emergency arteriography can be a most important diagnostic adjunct in the evaluation of suspected vascular injury sustained during penetrating maxillofacial trauma. Arteriography can provide essential information prior to operative exploration and treatment and may even obviate surgical exploration. Complications are rare, and contraindications are few.