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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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Madsen AS, Bruce JL, Oosthuizen GV, Bekker W, Laing GL, Clarke DL. The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective. World J Surg 2018; 42:3202-3209. [DOI: 10.1007/s00268-018-4595-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Vascular injuries remain among the most challenging entities encountered in trauma care. Improvements in diagnostic capabilities, resuscitation approaches, vascular techniques, and prosthetic device options have afforded considerable advancement in the care of these patients. This evolution in care capabilities continues. Despite advances, uncontrolled hemorrhage due to major vascular injury remains one of the most common causes of death after trauma. Successful management of vascular injury requires the timely diagnosis and control of bleeding sources; to facilitate this task, trauma providers must appreciate the capabilities and limitations of diagnostic imaging modalities. Trauma providers must understand when and how to effectively apply these strategies.
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Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg 2014; 75:936-40. [PMID: 24256663 DOI: 10.1097/ta.0b013e31829e20e3] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Simmons JD, Ahmed N, Donnellan KA, Schmieg RE, Porter JM, Mitchell ME. Management of Traumatic Vascular Injuries to the Neck: A 7-Year Experience at a Level I Trauma Center. Am Surg 2012. [DOI: 10.1177/000313481207800343] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.
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Affiliation(s)
- Jon D. Simmons
- Division of Trauma and Surgical Critical Care, University of South Alabama, Mobile, Alabama
| | - Naveed Ahmed
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Robert E. Schmieg
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - John M. Porter
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Marc E. Mitchell
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
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Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence based review of the assessment and management of penetrating neck trauma. Clin Otolaryngol 2012; 37:44-52. [PMID: 22152036 DOI: 10.1111/j.1749-4486.2011.02422.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format. TYPE OF REVIEW Structured, non-systematic review of recent medical literature. SEARCH STRATEGY An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day. EVALUATION METHOD Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance. RESULTS 147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation. CONCLUSIONS Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.
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Affiliation(s)
- C A Burgess
- Department of ENT Surgery, The Royal Berkshire Hospital, Reading, UK.
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Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM. Imaging vascular trauma. Br J Surg 2011; 99:494-505. [DOI: 10.1002/bjs.7763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 01/06/2023]
Abstract
Abstract
Background
Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.
Methods
A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.
Results
Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.
Conclusion
Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
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Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK
| | - M Cleanthis
- Imperial College Regional Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N Tai
- Trauma Clinical Academic Unit, Barts and the London NHS Trust, London, UK
| | - T Carrell
- National Institute for Health Research Comprehensive Biomedical Research Centre of Guy's and St Thomas' NHS Foundation Trust and Department of Vascular Surgery, King's College London, London, UK
| | - T M Loosemore
- St George's Vascular Institute, St George's University of London, London, UK
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Vascular surgery for penetrating injury of the neck*. Eur Surg 2011. [DOI: 10.1007/s10353-011-0045-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kubiak BD, Albert SP, Tandoh MA, Fortune JB, Cunningham PRG. Transverse sinus thrombosis after internal jugular vein ligation. J Emerg Med 2009; 43:e5-9. [PMID: 19682827 DOI: 10.1016/j.jemermed.2009.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 04/29/2009] [Accepted: 05/08/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral vein and dural sinus thrombosis is a rare condition with a wide range of causes and a highly variable presentation. It can lead to significant morbidity, but scant literature is available describing diagnosis and treatment when this occurs after ligation of the internal jugular vein. OBJECTIVES To discuss potential risk factors for cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein, and present current options for diagnosis and treatment. CASE REPORT A 23-year-old male construction worker was brought to the Emergency Department by Emergency Medical Services after sustaining a severe neck laceration from a hand-held grinder. He was treated with ligation of the left internal jugular vein, but subsequently developed severe headaches and symptoms of increased intracranial pressure. A magnetic resonance venogram of the head revealed a left transverse sinus thrombosis requiring treatment with anticoagulation. The placement of a lumboperitoneal shunt was ultimately needed for relief of his symptoms. CONCLUSIONS Early diagnosis and aggressive therapeutic interventions are critical to prevent further morbidity in patients who develop cerebral vein and dural sinus thrombosis after ligation of the internal jugular vein.
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Affiliation(s)
- Brian D Kubiak
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Munera F, Danton G, Rivas LA, Henry RP, Ferrari MG. Multidetector row computed tomography in the management of penetrating neck injuries. Semin Ultrasound CT MR 2009; 30:195-204. [PMID: 19537052 DOI: 10.1053/j.sult.2009.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Penetrating neck trauma may occur from gun shots, stabbings, and accidental injury. Approximately 50% of gunshot and 10%-20% of stab-wound patients are reported as having severe injuries and the mortality from severe vascular injuries is reported as high as 50%. Penetrating traumatic neck injury is no longer best managed with exploratory surgery or conventional angiography in the stable patient. Computed tomography angiography has proven to be a useful, safe, and reliable means of diagnosis. Experience with interpreting and reconstructing computed tomography images, understanding the clinically important findings, and avoiding pitfalls is critical for successful patient care. Therefore, radiologists and clinicians who treat trauma patients need to familiarize themselves with the computed tomography angiography technique and appearances of vascular injury and know when to recommend further evaluation, such as interventional angiography or open surgery.
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Affiliation(s)
- Felipe Munera
- Department of Radiology, Jackson Memorial Hospital/Ryder Trauma Center, University of Miami, Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136, USA.
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Dozier KC, Miranda MA, Kwan RO, Cureton EL, Sadjadi J, Victorino GP. Despite the increasing use of nonoperative management of firearm trauma, shotgun injuries still require aggressive operative management. J Surg Res 2009; 156:173-6. [PMID: 19577770 DOI: 10.1016/j.jss.2009.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/08/2009] [Accepted: 04/09/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The energy dissipation between gunshot and shotgun blasts is very different. Injuries from shotgun blasts vary depending on the distance of the victim from the shooter, the choke of the shotgun, the pellet load, and the wad of the ammunition. We postulated that gunshot and shotgun blasts create different injury patterns that dictate different treatment plans. METHODS Medical records of patients with gunshot and shotgun trauma were reviewed from 1998 through 2007 at our university-based trauma center. Statistical comparisons were made via Fisher's test or t-test calculations. RESULTS We evaluated 2833 patients injured by firearms; of these 61 had shotgun wounds (2.2%). The remainder sustained gunshot wounds. Mortality between shotgun and gunshot trauma patients was similar (7% versus 9%, respectively, P=0.8). There was no difference in the mean Injury Severity Score (ISS) (13.7+/-1.6 versus 12.9+/-0.2; P=0.6). Overall, 61% of patients underwent operative intervention after shotgun injuries versus 36% of patients with gunshot wounds (P<0.0001). Patients surviving shotgun injuries had a longer length of stay (10.1+/-2.0 d versus 5.9+/-0.21, P<0.05). CONCLUSIONS Although the injury severity was similar, injuries from shotguns required more operations and resource utilization. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous.
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Affiliation(s)
- Kristopher C Dozier
- Department of Surgery, University of California, San Francisco-East Bay, Alameda County Medical Center, Oakland, CA 94602, USA.
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