Selective management of gunshot wounds to the neck. Report of a series and review of the literature

Penetrating neck trauma: a case for conservative approach

BACKGROUND

Selective conservative management of penetrating neck trauma is a commonly adopted procedure to manage patients of such trauma. However, at places where trauma services are inadequate on different counts and a low-intensity military conflict is on, relevance of this approach without compromising the safety and well-being of the patient remains to be evaluated.

OBJECTIVES

The study aimed to address the relevance of selective conservative management of penetrating neck trauma in a low-intensity military conflict of Kashmir.

PATIENTS AND METHODS

This was a prospective case study of patients presenting to the ENT Head & Neck Surgery department with penetrating neck trauma for a 2-year period from June 2003 to May 2005. After a careful physical examination in the emergency room, immediate surgical intervention or a careful observation is planned. Relevant investigations in the latter group if indicated by clinical examination determined whether to operate or to continue such approach. The data were collected and analyzed.

RESULTS

Forty-six patients fulfilled the criteria to be included in the study. Eight patients (17.4%) underwent immediate surgical intervention, whereas the remaining patients (78.26%) were carefully observed for a minimum of 24 hours. Two patients of the active observation group required delayed exploration because of the close proximity of projectile to vessels. None of the patients in either group died. There was significant difference between the 2 groups in terms of hospital stay, use of diagnostic tests, and complications.

CONCLUSIONS

Selective conservative management is a cost-effective approach for penetrating neck trauma even in areas where there is relative paucity of advanced trauma services. These results further reinforce the validity of careful physical examination as a reliable tool to guide further management without necessarily resorting to expensive and at times difficult to do diagnostic tests.

Penetrating Neck Trauma in Operation Iraqi Freedom

Objectives. To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting.

Study Design. Case series with chart review.

Setting. Air Force Theater Hospital at Balad Air Base, Iraq.

Subjects and Methods. The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended.

Results. One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%.

Conclusions. The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

Detection and evaluation of aerodigestive tract injuries caused by cervical and transmediastinal gunshot wounds

BACKGROUND

Aerodigestive tract penetrations occurring with gunshot wounds to the neck and thorax are uncommon but are frequently associated with multiple organ injury and contribute to significant morbidity.

METHODS

The selective management strategy used at our institution for suspected aerodigestive tract involvement with cervical, thoracic inlet, and transmediastinal gunshot wounds is reviewed with reference to eight clinical cases from 1989 to 1995.

RESULTS

Seven pharyngoesophageal and four laryngotracheal injuries are described with three patients sustaining combined aerodigestive organ wounds. Associated injuries occurred in seven of the eight cases. Diagnosis of aerodigestive tract penetrations were made by triple endoscopy in five patients, by contrast esophagography in one case, and at operation for associated injuries in two patients. No injuries were missed during endoscopy or contrast studies. Two patients suffered complications including delayed recognition of an esophageal injury and pneumonia in one case and dehiscence of a distal esophageal repair in another. An associated vascular injury resulted in a single death in the series.

CONCLUSIONS

A high index of suspicion must be maintained for aerodigestive tract involvement with cervicothoracic gunshot wounds. We advocate operative endoscopic inspection during emergent exploration in unstable patients or arteriography with endoscopy in stable patients. Adjunctive contrast pharyngoesophagography is performed to confirm equivocal endoscopic findings, evaluate the extent of leak, or completely exclude injury.

Dynamic analysis of penetrating trauma

BACKGROUND

Whereas considerable literature exists on the wounding mechanics of high velocity projectiles in the military domain, there is a paucity of such data from projectiles routinely encountered in the civilian population in the United States. This study was undertaken to develop a methodology and to determine the dynamics of penetrating trauma secondary to low velocity projectiles (200-300 m/sec). To demonstrate the feasibility of the methodology and the experimental protocol, two markedly different projectiles were chosen in the study.

METHODS

Two projectiles were discharged into a human tissue simulant; one projectile was smooth and the other was of the expansion type. High-speed video photographic analysis and synchronized trigger techniques were used to describe the path of the projectile during its travel within the simulant. The temporal transient and residual profiles demonstrating the "wound involvement" were computed.

RESULTS

Results indicated a stark contrast between the two cases. There was a ratio of approximately three-to-one in the maximum wound involvement due to penetration. Transient wave oscillations during penetration and perforation of the projectile from the tissue simulant demonstrated significant differences in amplitudes and time durations. In addition, the residual wound involvement profiles indicated differences in the injury potential.

CONCLUSIONS

This study has provided an experimental methodology to delineate the temporal dynamic behavior of penetrating projectiles. To fully quantify and differentiate the dynamic differences in the temporal behaviors of the numerous available projectiles (with various combinations in design, type of equipment, and discharge), further research in this area is clearly necessary. The present protocol lends itself to be used to systematically analyze all these behaviors. Quantified data may assist clinical personnel in the management of penetrating trauma.

Tracheal rupture following blunt chest trauma presenting as endotracheal tube obstruction

In this report, we describe a patient in whom a tracheal tear followed blunt thoracic trauma. The diagnosis was made late resulting in problems with ventilation, endotracheal tube obstruction and cardiac arrest. Difficulties with early recognition of tracheobronchial injuries may be caused by non-specific findings as well as the lack of exposure of physicians to patients with these injuries. The signs and symptoms of tracheobronchial injuries are described, as well as their differential diagnoses. A review of airway management has been made as it requires combined anaesthetic and surgical expertise. Injuries of the trachea may have severe, life-threatening consequences and early diagnosis and management reduce morbidity and mortality.

Management of penetrating neck injuries. The controversy surrounding zone II injuries

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.

Penetrating neck wounds: is evidence of chest injury an indication for exploration?

A total of 94 patients who sustained a penetrating wound in the neck had evidence of chest penetration. Using a policy of selective management 19 were explored. All patients with important vascular injury were hypotensive on admission or had an expanding haematoma. There were no complications in the 75 patients who were managed conservatively. Penetration of the chest is not an indication for exploration in neck wounds.

Management of airway trauma. II: Combined injuries of the trachea and esophagus

Twenty-four consecutive patients with combined injuries of the trachea and esophagus were operated on at the Tulane University Hospital and the Charity Hospital of New Orleans between 1967 and 1983. Only 3 of the injuries resulted from blunt trauma, and 1 of these patients had a total transection of both the trachea and esophagus; the remaining injuries were due to penetrating trauma (20 gunshot wounds; 1 stab wound). The combined lesions involved the cervical region in 20 patients and the thoracic esophagus and trachea or bronchus in 4. All patients underwent bronchoscopy; in recent years all have had esophagoscopy, because our experience indicates that esophagrams, which patients also underwent, have a high rate (12.5%) of false negative results. Operative techniques included a two-layer closure of all esophageal injuries, closure of the trachea with non-absorbable monofilament suture, and transthoracic or cervical drainage. Muscle flaps were used for suture line reinforcement. Associated operative procedures included tracheostomy (5), laparotomy (4), vascular procedures (5), neurologic procedures (2), and closed-tube thoracostomy (6). Five patients (21%) died in the perioperative period, 4 of 20 with combined cervical injuries, and 1 of the 4 with combined thoracic injuries. Deaths resulted from missed injuries to the esophagus (2 patients), a missed tracheal injury (1), associated vascular injury (1), and associated thoracoabdominal injury (1). Two patients experienced cervical esophageal suture line leaks, both of which sealed with conservative therapy. Clinical follow-up showed good results in 90% of the patients who survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of airway trauma. I: Tracheobronchial injuries

One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 20 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 100 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 106 patients (16.98%), including 11 (13.75%) of 80 with injuries of the cervical trachea. Seven (53.8%) of 13 with principal injuries of the thoracic trachea died; all 13 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (23%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and 3 (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Air gun injuries in children

Air gun injuries occur frequently in children and are potentially lethal. Three cases of air gun injuries in children are described. Two children sustained air gun injuries to the neck that penetrated the platysma. Each had exploration of the wound. One had injury to the esophagus that was treated with external drainage; the other sustained no major injury to vital cervical structures. A third child received a penetrating injury to her right flank that did not appear to enter the peritoneal cavity. She was observed for 24 hours and released. After a six-month followup, all patients have remained free of complications. The emergency physician should be aware of the penetrating capabilities of these weapons, and they should be managed as would any other low-velocity gunshot wound.

Operation or observation for penetrating neck wounds? A retrospective analysis

A review of 83 patients with penetrating neck wounds was performed to assess the relative merits of operation versus observation. Fifty patients (60 percent) underwent immediate surgery, 28 of whom (56 percent) had no significant neck injury. There were no deaths and only two complications (4 percent). Thirty-three patients (40 percent) were treated with initial observation, one of whom required subsequent surgery. In the latter group, there were also no deaths and two complications (6 percent). Length of hospital stay did not differ between patients with negative findings on exploration and those observed. When clinical signs as indications for surgery were present, management was more often correct than when signs were absent (82 and 52 percent, respectively), but the presence or absence of signs correctly predicted injury or lack of injury in over 80 percent of the patients. These data demonstrate the safety and efficacy of selective observation of patients with penetrating neck trauma, and confirm that clinical signs are a reliable indicator of significant injury.