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Siletz A, Inaba K. Diagnostic approach to penetrating neck trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:175-182. [PMID: 38523116 DOI: 10.1097/ta.0000000000004292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Anaar Siletz
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (A.S., K.I.), Los Angeles General Medical Center; and Keck School of Medicine (A.S., K.I.), University of Southern California, Los Angeles, California
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2
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Muñoz CA, Hadad AG, González P, Burgos A, Ordoñez CA, Serna JJ. Carotid artery penetrating trauma: Report of 4 cases and literature revision. Int J Surg Case Rep 2024; 121:109940. [PMID: 38971033 PMCID: PMC11269920 DOI: 10.1016/j.ijscr.2024.109940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE In penetrating neck trauma, carotid artery penetrating trauma is considered one of the most complicated injuries to treat. Active bleeding, large hematomas, and rapid occlusion of the airways make the surgical approach to controlling bleeding and repairing the vessel much more complex, constituting an essential clinical challenge to every surgeon. CASE PRESENTATION We present 4 cases of patients with carotid artery penetrating trauma. Two patients were treated with endovascular therapy, one with surgery, and the fourth one treated conservatively. None of the patients had posterior neurological impairment. CLINICAL DISCUSSION Carotid artery penetrating trauma is uncommon yet is associated with high rates of mortality and neurological impairment. The common carotid artery is the most frequently injured, and gunshot wounds (GSW) are the most frequent trauma mechanism. Angiotomography (CTA) is the first-line exam for diagnosing these injuries. Treatment should be prompt and individualized and may include conservative techniques, endovascular therapy, and traditional surgical repair. CONCLUSION Carotid artery penetrating trauma is an uncommon but complex injury that requires a timely diagnosis and treatment to avoid potentially devastating consequences, particularly in hemodynamically unstable patients. Traditionally, the treatment strategies for these injuries used to be limited to vascular repair or ligation. However, endovascular therapy and conservative management are viable alternatives, which have become more and more useful in selected patients, allowing less invasive approaches with fewer morbidity and acceptable results.
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Affiliation(s)
- Carlos Andres Muñoz
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.
| | - Adolfo González Hadad
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.
| | - Paola González
- Departamento de Cirugía General, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Alejandro Burgos
- Departamento de Cirugía General, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Carlos Alberto Ordoñez
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia; Departamento de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - José Julián Serna
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia; Departamento de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
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3
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Chandrananth ML, Lee JD, Read D, Shakerian R. 'No zone' approach in the management of penetrating neck injuries - an Australian Tertiary Trauma Centre experience. ANZ J Surg 2024; 94:591-596. [PMID: 38525869 DOI: 10.1111/ans.18939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/20/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024]
Abstract
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.
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Affiliation(s)
- Meera L Chandrananth
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Trauma Service, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jordan D Lee
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Trauma Service, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - David Read
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Trauma Service, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rose Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Trauma Service, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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4
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Hamilton JM, Chan TG, Moore CE. Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols. Otolaryngol Clin North Am 2023; 56:1013-1025. [PMID: 37353366 DOI: 10.1016/j.otc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.
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Affiliation(s)
- James M Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Tyler G Chan
- Emory University School of Medicine, Atlanta, GA, USA
| | - Charles E Moore
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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5
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Deb T. Management of an Unusual Penetrating Neck Injury with an Iron Rod in a Tertiary Care Centre. Indian J Otolaryngol Head Neck Surg 2023; 75:2488-2491. [PMID: 37636776 PMCID: PMC10447767 DOI: 10.1007/s12070-023-03737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/26/2023] [Indexed: 08/29/2023] Open
Abstract
The majority of the neck injuries are linked either to aggression or self inflicted cut throat or firearm injuries. Here we present a rare case of a penetrating neck injury by an iron rod, which was sustained due to accidental fall at home. A very long, rusted, iron TMT bar about 10 mm diameter, with entangled clothing with hooks on it, had penetrated the neck of the patient from below the mandible in the left side and exited through the oral cavity on the right angle of the mouth. The patient was under alcohol intoxication, however was stable as far as vital signs were concerned. There was no active bleeding or expanding haematoma neither there was any stridor or neurological deficit. The patient was further stabilised and after doing the necessary investigations he was taken up for surgery under general anaesthesia and the rod was successfully removed and the wound repaired. The patient recovered uneventfully and quickly and was discharged on the fifth post operative day. Accidental penetrating neck injuries are not very common and internet search did not reveal many published cases. Penetrating neck injuries are usually attached with high morbidity and mortality, because of damage to great vessels and nerves. A good knowledge of the anatomy and proper assessment of the injury before removal is a prerequisite before removal. With a little bit of courage and adopting a multidisciplinary approach and good computed tomography (CT) scan to assess the injury, such cases can be easily handled.
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Affiliation(s)
- Tanmoy Deb
- Department of ENT and Head & Neck Surgery, Agartala Government Medical College and GB Pant Hospital, Agartala, Tripura 799006 India
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6
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Kee-Sampson JW, Gopireddy DR, Vulasala SSR, Stein R, Kumar S, Virarkar M. Role of imaging in penetrating vascular injuries of the craniocervical region. J Clin Imaging Sci 2022; 12:63. [PMID: 36601604 PMCID: PMC9805603 DOI: 10.25259/jcis_98_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022] Open
Abstract
Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.
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Affiliation(s)
- Joanna W. Kee-Sampson
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Dheeraj Reddy Gopireddy
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sai Swarupa Reddy Vulasala
- Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.,Corresponding author: Sai Swarupa Reddy Vulasala, Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.
| | - Rachel Stein
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sindhu Kumar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Mayur Virarkar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
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7
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Ricardo-Sagra M, Ayala Perez SC, Sanguino-Jaramillo MG, Alzate JP. Manejo conservador de lesión aerodigestiva: reporte de un caso y revisión de la literatura. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El trauma penetrante de cuello representa un evento desafortunado de baja incidencia y alta complejidad diagnóstica y terapéutica, lo que supone un reto para el cirujano general.
Caso clínico. Paciente femenina de 20 años de edad, quien sufrió una herida cervical por proyectil de arma de fuego, desarrollando de forma secundaria una lesión aerodigestiva. Se realizó un tratamiento expectante en un hospital de alta complejidad, con una evolución favorable.
Discusión. En la literatura existe un claro debate en cuanto al manejo de las lesiones penetrantes en cuello y la sospecha de lesión orgánica oculta. En nuestro paciente la lesión aerodigestiva fue tratada mediante observación y seguimiento clínico.
Conclusiones. El manejo de un paciente con lesión aerodigestiva se puede corroborar mediante las imágenes diagnósticas y se puede tratar de forma expectante con un resultado exitoso, sin agregar morbilidad y con un impacto adecuado en el buen uso de los recursos disponibles.
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8
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Choi KK, Cho J, Lee MA, Eun SM, Jeon YB. Successful management of a common carotid artery injury using a Pruitt-F3 Carotid Shunt: a case report. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Spontaneous Recovery of Penetrating Cervical Spinal Cord Injury with Physiotherapeutic Treatment: Case Report and Review of the Literature. Case Rep Neurol Med 2022; 2021:3741461. [PMID: 34987873 PMCID: PMC8720595 DOI: 10.1155/2021/3741461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Stab wounds to the cervical spine are less common than injuries from road accidents, sports injuries, and falls. The presence of vital, vascular, neural, respiratory, and digestive structures in the neck region mean that this kind of spinal injury is generally critical, and its management is a challenge. We report a unique case of a previously healthy 17-year-old adolescent admitted for quadriplegia secondary to a stab wound to the cervical spine at the C4C5 level. There was no surgical indication. The patient underwent physiotherapy. He showed spontaneous neurological improvement two weeks later and was able to sit on his own and to walk about three months of physical rehabilitation.
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10
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Ichibayashi R, Suzuki G, Nakamichi Y, Yamamoto S, Serizawa H, Watanabe M, Harada M, Harada N, Honda M. Penetrating vertebral artery injury treated by combining the "zone" approach and imaging tests: A case report. Clin Case Rep 2021; 9:e05134. [PMID: 34849232 PMCID: PMC8609188 DOI: 10.1002/ccr3.5134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/18/2022] Open
Abstract
Patients with vertebral artery injury from penetrating neck trauma may not present with signs of vascular injury because of anatomical characteristics and concomitant conditions, such as hypothermia and shock. If patients are hemodynamically stable, imaging tests should be performed to examine the posterior components, including the vertebral artery.
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Affiliation(s)
- Ryo Ichibayashi
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Ginga Suzuki
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Yoshimi Nakamichi
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Saki Yamamoto
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Hibiki Serizawa
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Masayuki Watanabe
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Masashi Harada
- Department of NeurosurgeryToho University Medical Center Omori HospitalOta‐kuJapan
| | - Naoyuki Harada
- Department of NeurosurgeryToho University Medical Center Omori HospitalOta‐kuJapan
| | - Mitsuru Honda
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
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11
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Das S, Lakshmanan J, Alexander A, Hansdah R. Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm. BMJ Case Rep 2021; 14:e244098. [PMID: 34493559 PMCID: PMC8424826 DOI: 10.1136/bcr-2021-244098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/04/2022] Open
Abstract
External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.
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Affiliation(s)
- Sauradeep Das
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Jijitha Lakshmanan
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Arun Alexander
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Rashmi Hansdah
- ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
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12
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Imaging Modalities in Trauma and Emergency—a Review. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02346-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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13
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Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg 2021; 89:1233-1238. [PMID: 32890346 DOI: 10.1097/ta.0000000000002919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT. METHODS We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017. RESULTS A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%. CONCLUSIONS This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients. LEVEL OF EVIDENCE Systematic review, level IV.
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14
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Joseph AP, Newey A, Glover A, Mohabbat W. An unusual case of a penetrating neck injury (PNI) illustrating the use of a "no zone" approach for the management of this injury and a review of the literature. Trauma Case Rep 2021; 32:100402. [PMID: 33644288 PMCID: PMC7892993 DOI: 10.1016/j.tcr.2021.100402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/29/2022] Open
Abstract
We present an unusual case of a young male with a penetrating neck injury (PNI) due to a work-related injury. A metallic foreign body traversed from entry at surgical Zone 2 to Zone 1 in the neck and resulted in a transection of the left thyrocervical trunk at the origin with the left subclavian artery. Computed Tomographic Angiography (CTA) of the aortic arch and major branch vessels demonstrated haemorrhage anterior to the left subclavian artery and left thyrocervical trunk. We describe some of the diagnostic and operative challenges which may occur in these rare and life-threatening injuries. We have also reviewed some of the recent key literature on this topic and have collated the recommendations of the review. In recent years, there has been a movement away from selective “zone-based” mandatory surgical exploration for Zone 2 injuries, as well as invasive and time-consuming investigations (such as digital subtraction angiography, contrast oesophageal swallow and bronchoscopy) for Zone 1 and 3 injuries due to the high number of negative surgical procedures and investigations. We demonstrate there is now an evidence-based algorithm which demonstrates that a “no zone” approach to the management of these patients is safe and effective. This requires an initial physical examination looking for the presence or absence of “hard”, “soft” or “no” physical signs in these patients, and then deciding on subsequent management which would include immediate surgery, CTA of the aortic arch and branches (and subsequent surgical or other management) or observation only. Our aim in describing this case it to highlight that there is now good evidence-based guidance for the safe and effective management of patients with this infrequent but potentially fatal injury.
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Affiliation(s)
- A P Joseph
- Emergency Department and Trauma Service, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - A Newey
- Radiology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - A Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - W Mohabbat
- Department of Vascular Surgery, Royal North Shore Hospital, St Leonards, NSW 2056, Australia
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15
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Bazzout A, Lachkar A, Benfadil D, Tsen AA, El Ayoubi F, Ghailan R. About an unusual penetrating cervical wound:Iron bar. Ann Med Surg (Lond) 2021; 62:197-199. [PMID: 33537128 PMCID: PMC7843356 DOI: 10.1016/j.amsu.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The majority of cervical wounds are linked to aggressions and attempted autolysis by knives or firearms. Case presentation the story is about a 35 -year-old man admitted to the emergency room for a penetrating cervical wound following an accidental fall in the workplace. The extremely long iron bar (concrete)has penetrated its neck on the right side.upon admission, the patient was conscious,hemodynamically and respiratory stable without sensory-motor deficit. Surgical exploration is urgently decided under general anesthesia, from wich the foreign body is successfully removed.A follow -up examination at 4 months was without particularity. Discussion Penetrating neck injuries caused by objects such as rods or iron bars pose a significantly high risk of serious neurological damage. Penetrating neck injuries can be life-threatening and functional.the extent of the lesions must be assessed precisely before removing the foreign body. Conclusion we report an exceptional case of a penetrating neck wound caused by a concrete iron bar.treatment should always be multidisciplinary and giving priority to vital structures and function. The majority of cervical wounds are linked to aggressions and attempted autolysis by knives or firearms. The management of trauma to the penetrating neck has gone from compulsory exploration of the neck to selective management. The care is multidisciplinary because it calls upon several stakeholders to know: the surgeon of head and neck, vascular surgeon and anesthesiologist and only an early appropriate treatment can reduce the sequel.
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Affiliation(s)
- Asmae Bazzout
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Azzeddine Lachkar
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Drissia Benfadil
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Adil Abdenbi Tsen
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Fahd El Ayoubi
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Rachid Ghailan
- University Hospital Center Mohamed VI, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
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16
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Chandrananth ML, Zhang A, Voutier CR, Skandarajah A, Thomson BNJ, Shakerian R, Read DJ. 'No zone' approach to the management of stable penetrating neck injuries: a systematic review. ANZ J Surg 2021; 91:1083-1090. [PMID: 33480177 DOI: 10.1111/ans.16600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aim: to review outcomes of the 'no zone' approach to penetrating neck injuries (PNIs) with the advent of high-fidelity computed tomography-angiography (CT-A) in order to determine the most appropriate management for stable PNIs. DESIGN Systematic review. POPULATION Retrospective and prospective cohort studies of patients who sustained penetrating neck trauma, as defined by an injury which penetrates the platysma, and whose initial management involved CT-A evaluation. METHODS An extensive literature search was performed in July 2019 using the following databases: Pubmed Central, EMBASE, Medline and Cochrane CENTRAL. Only studies published in English from the last 15 years were included. RESULTS Nine cohort studies met inclusion criteria. There has been an increase in CT-A focussed evaluation of PNIs in recent years. CT-A is a highly sensitive and specific imaging choice and reduces negative neck exploration rates. A new management algorithm for stable patients involving initial radiological assessment using CT-A, and subsequent selective surgical exploration, is safe and effective. CONCLUSION The results of this review provide level 2A evidence that the 'no zone' approach to PNIs, complemented by CT-A and thorough clinical assessment, is a safe management strategy which reduces negative neck exploration rates.
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Affiliation(s)
- Meera L Chandrananth
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew Zhang
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Catherine R Voutier
- Health Sciences Library, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anita Skandarajah
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rezvaneh Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David J Read
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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17
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Herrera MA, Tintinago LF, Victoria Morales W, Ordoñez CA, Parra MW, Betancourt-Cajiao M, Caicedo Y, Guzmán-Rodríguez M, Gallego LM, González Hadad A, Pino LF, Serna JJ, García A, Serna C, Hernández-Medina F. Damage control of laryngotracheal trauma: the golden day. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4124599. [PMID: 33795902 PMCID: PMC7968428 DOI: 10.25100/cm.v51i4.4422.4599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Laryngotracheal trauma is rare but potentially life-threatening as it implies a high risk of compromising airway patency. A consensus on damage control management for laryngotracheal trauma is presented in this article. Tracheal injuries require a primary repair. In the setting of massive destruction, the airway patency must be assured, local hemostasis and control measures should be performed, and definitive management must be deferred. On the other hand, management of laryngeal trauma should be conservative, primary repair should be chosen only if minimal disruption, otherwise, management should be delayed. Definitive management must be carried out, if possible, in the first 24 hours by a multidisciplinary team conformed by trauma and emergency surgery, head and neck surgery, otorhinolaryngology, and chest surgery. Conservative management is proposed as the damage control strategy in laryngotracheal trauma.
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Affiliation(s)
- Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Tintinago
- Fundación Valle del Lili, Department of Surgery, Division of Head and Neck Surgery, Cali, Colombia
| | - William Victoria Morales
- Fundación Valle del Lili, Department of Surgery, Division of Head and Neck Surgery, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | | | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | | | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Carlos Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fabian Hernández-Medina
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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18
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Quax MLJ, Eefting D, Jansen JC, Blok JJ. A 'Final Destination injury': Penetrating trauma of the neck and a pneumomediastinum by a metal part shot from a lawnmower. Trauma Case Rep 2020; 31:100379. [PMID: 33364293 PMCID: PMC7750575 DOI: 10.1016/j.tcr.2020.100379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 10/31/2022] Open
Abstract
Introduction Outside of war regions, penetrating neck injury is rare. Penetrating neck injury due to a lawnmower has never been described, despite the annual 74.000 injuries caused by lawnmowers in the United States. In this report, the case of a 65-year old women, admitted after a penetrating neck injury due to a metal piece shot from a lawnmower, is described. Report A 65-year old women, with no relevant medical history, presented at the Emergency Department after she was hit in the neck by an iron projectile shot from a professional lawnmower. On site, the projectile, a metal part from the lawnmower blade, was removed by her husband. CT scan showed a pneumomediastinum, without signs of vascular injury. Surgical exploration was immediately performed in the operation room (OR). No vascular or esophageal injuries werefound, only lacerated neck muscles. Perioperatively, the ENT surgeon performed an endoscopy, which showed a small injury of the hypopharynx. Postoperatively, the patient was prophylactically treated with antibiotics for 7 days. Patient was discharged in good clinical condition after 7 days, without complications. Conclusion In this report we present a case with a sharp traumatic injury of the neck, caused by a metal projectile shot from a lawnmower. The laceration of the pharynx was explored in the OR by the ENT- and vascular surgeon. The pneumomediastinum was treated with prophylactic antibiotics. Currently the patient is doing fine without any complications of the injury. Traumatic injury of the neck requires direct direct surgical exploration, however, when patients present hemodynamically stable, a neck CTA will add to the diagnosis (e.g. a pneumomediastium).
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Affiliation(s)
- Marcel L J Quax
- Departments of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daniel Eefting
- Departments of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen C Jansen
- Departments of Otorhinolaryngology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joris J Blok
- Departments of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
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19
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Ko JW, Gong SC, Kim MJ, Chung JS, Choi YU, Lee JH, Jung PY. The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study. Ann Surg Treat Res 2020; 99:352-361. [PMID: 33304863 PMCID: PMC7704270 DOI: 10.4174/astr.2020.99.6.352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/11/2020] [Accepted: 10/09/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose Recently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the “no zone” approach in traumatic neck injuries. Methods Medical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the “zone” and/or no zone approach. Results Out of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55–157.60). Conclusion Traumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.
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Affiliation(s)
- Ji Wool Ko
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Myung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jae Sik Chung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Young Un Choi
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jun Hyuk Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
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20
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Christian AB, Maithel S, Grigorian A, Kabutey NK, Dolich M, Kong A, Gambhir S, Sheehan BM, Nahmias J. Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury. Ann Vasc Surg 2020; 72:440-444. [PMID: 32949747 DOI: 10.1016/j.avsg.2020.08.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected. METHODS The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality. RESULTS A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95). CONCLUSIONS The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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Affiliation(s)
- Ashton B Christian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Shelley Maithel
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Matthew Dolich
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Allen Kong
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA.
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21
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Adams A, Shah N, Stephenson R. An approach to accurate computed tomography imaging interpretation in penetrating neck trauma. Acta Radiol Open 2020; 9:2058460120938742. [PMID: 32655886 PMCID: PMC7328502 DOI: 10.1177/2058460120938742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/07/2020] [Indexed: 12/20/2022] Open
Abstract
Penetrating neck injury can have potentially devastating consequences due to the many
vital structures contained within the neck. In patients who do not require immediate
surgery, computed tomography angiography of the neck is the test of choice to characterize
the injury. A systematic approach to assessment will ensure a thorough evaluation and give
the reporting radiologist the best chance of identifying the significant findings, which
can often be subtle. Clear communication with the trauma team at both the time of request
and after the imaging has been evaluated to relay any significant findings is vital to
ensure the best outcome for the patient.
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Affiliation(s)
- Ashok Adams
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Nimesh Shah
- Barts Health NHS Trust, The Royal London Hospital, London, UK
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22
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Madsen AS, Bruce JL, Oosthuizen GV, Bekker W, Smith M, Manchev V, Laing GL, Clarke DL. Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach. BJS Open 2020; 4:704-713. [PMID: 32525254 PMCID: PMC7397367 DOI: 10.1002/bjs5.50282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- A S Madsen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - W Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - M Smith
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - V Manchev
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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23
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Jenkins LN, Rezende-Neto JB. Current Management of Penetrating Traumatic Cervical Vascular Injuries. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00258-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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24
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Asensio JA, Dabestani PJ, Wenzl FA, Miljkovic SS, Kessler JJ, Fernandez CA, Becker T, Cornell D, Siu M, Voigt C, Agrawal DK. A systematic review of penetrating extracranial vertebral artery injuries. J Vasc Surg 2020; 71:2161-2169. [DOI: 10.1016/j.jvs.2019.10.084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
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25
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Isaza-Restrepo A, Quintero-Contreras JA, Escobar-DiazGranados J, Ruiz-Sternberg ÁM. Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test. BMC Emerg Med 2020; 20:17. [PMID: 32151240 PMCID: PMC7063736 DOI: 10.1186/s12873-020-00311-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/14/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Andrés Isaza-Restrepo
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia. .,Méderi Hospital Universitario Mayor, Bogotá, DC, Colombia.
| | | | - Jorge Escobar-DiazGranados
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Ángela María Ruiz-Sternberg
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia
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26
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Debelmas A, Lanciaux S, Bontemps P, Khonsari RH. A sore throat. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2019; 121:454-456. [PMID: 31476541 DOI: 10.1016/j.jormas.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/12/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
Abstract
The authors report an unusual case of penetrating anterior neck injury in a 71-year-old female patient, who intentionally stabbed herself in a suicide attempt. The initial clinical and radiological assessment revealed that the knife had pierced through the sixth vertebral body and spinal cord, avoiding all the vital structures on the way. Surgical removal of the knife was successfully performed, and the patient was rapidly discharged, with mild neurological impairment. Although frequently described in posterior locations, neurological lesions are rare in anterior neck injuries. This case emphasizes the fact that a thorough neurological examination should be conducted in all neck injuries.
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Affiliation(s)
- A Debelmas
- Service de chirurgie maxillo-faciale et stomatologie, université Pierre et Marie Curie, Sorbonne universités, hôpital Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75013 Paris, France.
| | - S Lanciaux
- Service de chirurgie maxillo-faciale et stomatologie, université Pierre et Marie Curie, Sorbonne universités, hôpital Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75013 Paris, France
| | - P Bontemps
- Service de chirurgie maxillo-faciale et stomatologie, université Sorbonne Paris Cité, université Paris Diderot, hôpital Beaujon, Assistance publique-hôpitaux de Paris, 92110 Paris, France
| | - R H Khonsari
- Service de chirurgie maxillo-faciale et plastique, université Paris Descartes, université Sorbonne Paris Cité, centre de référence des fentes et malformations faciales (MAFACE), Hôpital Necker-Enfants-Malades, Assistance publique-hôpitaux de Paris, 75015 Paris, France
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27
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Hundersmarck D, Reinders Folmer E, de Borst GJ, Leenen LPH, Vriens PWHE, Hietbrink F. Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem. Eur J Vasc Endovasc Surg 2019; 58:455-462. [PMID: 31307866 DOI: 10.1016/j.ejvs.2019.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
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Petrone P, Velaz-Pardo L, Gendy A, Velcu L, Brathwaite CEM, Joseph DK. Diagnosis, management and treatment of neck trauma. Cir Esp 2019; 97:489-500. [PMID: 31358299 DOI: 10.1016/j.ciresp.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/27/2019] [Accepted: 06/02/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Patrizio Petrone
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU..
| | - Leyre Velaz-Pardo
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Amir Gendy
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Laura Velcu
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Collin E M Brathwaite
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - D'Andrea K Joseph
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
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Penetrating neck trauma: radiological predictors of vascular injury. Eur Arch Otorhinolaryngol 2019; 276:2541-2547. [PMID: 31218447 DOI: 10.1007/s00405-019-05517-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Vascular injury in penetrating neck trauma predicts a poorer outcome and usually requires surgical neck exploration. Multi-detector computed tomography (MDCT) angiography is a readily available non-invasive diagnostic tool that can identify direct and indirect signs of vascular injury in stable patients. This study aims to investigate the diagnostic accuracy of radiological signs of vascular injury on MDCT, and their implications on patient management in the setting of penetrating neck trauma. METHODS A retrospective cohort study of penetrating neck injuries (PNI) between 2012 and 2018 in a UK major trauma centre was performed. Clinical data and operative findings were compared with radiological findings on MDCT performed at the time of admission. RESULTS 157 patients were identified with PNI in the study period, with 67 meeting inclusion criteria. The predictive value of indirect radiological signs of vascular injury alone was low, with only 12.1% of these patients having significant vascular injury found at neck exploration. However, the combined use of direct radiological signs with clinical signs resulted in a specificity of 97.7% for vascular injury. CONCLUSIONS The use of direct and indirect radiological signs of vascular injury can increase the accuracy of diagnosis when used in conjunction with clinical signs. Combining clinical assessment and radiological investigation, specifically contrast-enhanced MDCT, improves the specificity in pre-operative assessment of potential vascular injury in PNI. MDCT is recommended in stable patients with clinical signs of vascular injury to reduce the rate of negative neck exploration.
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Abstract
Penetrating injuries to the internal carotid artery are infrequent but potentially devastating and can be a significant challenge to the operating surgeon. In this article, we present a case of an 11-year-old girl who suffered a serious vascular injury when she fell on a pencil. We also discuss the most up-to-date recommendations concerning the management of zone II injuries to the neck of a paediatric patient.
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Affiliation(s)
- Monica Abdelmasih
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Kayssi
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Wang D, Zhao Y, Cha B, Fang P, Liu Y. Penetrating neck trauma with common carotid artery injury caused by a percussive drill: A case report. Medicine (Baltimore) 2019; 98:e15750. [PMID: 31145290 PMCID: PMC6709122 DOI: 10.1097/md.0000000000015750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Penetrating neck traumas are dangerous and have a high mortality rate, particularly in patients with common carotid artery injuries. Advances in diagnostic imaging technology have shifted management of penetrating neck injuries from mandatory exploration to selective management. The question is now regarding optimal selection of auxiliary examinations to assess "stability" rapidly and guide clinics in managing such patients. PATIENT CONCERNS A 56-year-old man suffered neck trauma with the right common carotid artery caused by a percussive drill. The carotid artery could not be clearly displayed in computed tomography (CT) angiography imaging. DIAGNOSES Penetrating neck trauma due to percussive drill bit with common carotid artery injury. INTERVENTIONS X-ray and bedside duplex ultrasound with color Doppler flow imaging were used to assess the state of trauma and the foreign body was removed under general anesthesia. OUTCOMES The patient was discharged at postoperative day 10 with no complication. The patient had no sequelae from this injury at 6-month follow up. LESSONS X-ray provides a comprehensive assessment of damage, and can efficiently detect foreign bodies in the skull and cervical vertebrae. Duplex ultrasound to be a viable method to exclude macrovascular injury in unstable patients who are not eligible for computed tomography angiography (CTA) or catheter angiography imaging. Widely available duplex ultrasound and x-ray should be considered in emergency situations.
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Affiliation(s)
| | - Yi Zhao
- Department of Otorhinolaryngology
| | - Bingshan Cha
- Department of Vascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Neck Injuries: a Complex Problem in the Deployed Environment. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0155-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Wang Y, Sun Y, Zhou T, Liu GH, Zhang XM, Yue JX, Xiong XG, Liu BH, Yang CZ, Kong W, Wang YJ. Penetrating neck trauma caused by a rebar: A case report. Medicine (Baltimore) 2018; 97:e0468. [PMID: 29668621 PMCID: PMC5916684 DOI: 10.1097/md.0000000000010468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Yan Wang
- Department of Otorhinolaryngology
| | - Yu Sun
- Department of Otorhinolaryngology
| | - Tao Zhou
- Department of Otorhinolaryngology
| | - Guo-hui Liu
- Department of Orthopaedic, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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"No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res 2017; 221:113-120. [PMID: 29229116 DOI: 10.1016/j.jss.2017.08.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/04/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
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.
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Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures. Curr Opin Otolaryngol Head Neck Surg 2017; 25:527-532. [PMID: 28877048 DOI: 10.1097/moo.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The primary purpose of this chapter is to define current recommendations for vascular work-up of patients with craniomaxillofacial (CMF) trauma with emphasis on imaging to include intraoperative fluorescence, angiography, and surgical exploration. The second goal is to review current management recommendations for observation versus surgical exploration based on the neck zones of injury. RECENT FINDINGS Over the past two decades, endovascular techniques are increasingly utilized, particularly in zones I and III of the neck. Additionally, modern advances in radiographic technology have allowed for selective exploration of penetrating zone II injuries. A high suspicion for blunt cerebrovascular injury should be maintained for patients with high-speed deceleration mechanisms of injury, with a majority of patients managed with medical therapy or conservative monitoring over surgical intervention. SUMMARY CMF fractures are associated with vascular injuries to the intracranial carotid system, extracranial carotid system, or vertebral artery system. A thorough understanding of at risk patients, optimal work-up, and timely treatment algorithms is imperative given the devastating sequellae of stroke and death.
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A Bullet Lying Next to the Common Carotid Artery in the Neck of a Young Boy. J Craniofac Surg 2017; 28:190-192. [DOI: 10.1097/scs.0000000000003243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Peng CZ, Wang CY. Elderly with gunshot injury crossing zones I to III of the neck. Eur Geriatr Med 2016. [DOI: 10.1016/j.eurger.2015.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Defining Zone I of penetrating neck trauma: A surgical controversy in the light of clinical anatomy. J Trauma Acute Care Surg 2016; 80:670-3. [PMID: 26808025 DOI: 10.1097/ta.0000000000000978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Bhatt NR, McMonagle M. Penetrating neck injury from a screwdriver: can the No Zone approach be applied to Zone I injuries? BMJ Case Rep 2015; 2015:bcr-2015-212666. [PMID: 26621867 DOI: 10.1136/bcr-2015-212666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The newer approach to management of penetrating neck injuries (PNI) involves the No Zone approach: comprehensive physical examination combined with CT angiography for triage to effectively identify or exclude vascular and aerodigestive injury. This approach, however, has a low negative exploration rate; there is risk of missing occult injuries especially Zone I and III PNI. We report a case of a patient with PNI to Zone I of the neck who was haemodynamically stable at presentation; CT scan revealed complete occlusion of the common carotid artery. Immediate surgical exploration revealed an occult hypopharyngeal injury in addition to the arterial trauma, which was missed on the CT scan. Hence the No Zone approach needs cautious clinical application, especially in Zone I injuries.
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Affiliation(s)
- Nikita R Bhatt
- Department of Surgery, University Hospital Waterford, Waterford, Ireland Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Morgan McMonagle
- Department of Surgery, University Hospital Waterford, Waterford, Ireland
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