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

Acute successful management of a chainsaw injury to the roof of the left chest

This case report chronicles the experience of prompt resuscitation, beginning with the patient, and immediate surgery following the fatal malfunction of a chainsaw. The injuries were atypical for chainsaw injuries and involved total transection of the left subclavian artery and vein, total transection of the left brachial plexus and laceration to the apex of the left lung, among other injuries. A coordinated effort allowed for successful repair of the life- and limb-threatening injuries so that the patient could return to his young family in time for his 40th birthday.

Explore no more: Early experience with a novel minimally invasive approach to penetrating trauma to zone II of the neck

The traditional approach to penetrating injuries to zone II of the neck has included operative neck exploration, extensive enough to allow for proximal and distal vascular control of the potential vascular injury. Few studies have reported cases of entirely endovascular management of penetrating injury to this portion of the neck. In the present case report, we describe the case of a 38-year-old man who had sustained a stab wound to zone II of the neck. The injury to the internal carotid artery was managed endovascularly with placement of a covered stent. The findings from the present case illustrate the potential use of minimally invasive vascular treatment strategies as an alternative to mandated operative intervention.

Safety in selective surgical exploration in penetrating neck trauma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pediatric arrowshot injury to cervical spinal cord-sagittal cord transection with no neurological deficit and good outcome: case report and review of literature

BACKGROUND

Penetrating spinal cord injuries (PSCI) in cervical region are extremely rare in children. They mostly occur in a mechanism of a gunshot or a stab injury with the use of sharp objects. Gunshot injuries are usually fatal or end up with tetraplegia. Stab wounds may be less severe and result in partial neurological syndrome. In the management of PSCI in children, reliable diagnostics and history of the patient are the most valuable for further decisions, which include early or delayed exploration either nonsurgical treatment. There exist no clear algorithm for antibiotic use in pediatric population--it depends on the site of an injury, presence of pathological secretion from the wound, and nature of the trauma. The use of steroids is controversial. The most common complications related to surgery include infections, edema, and hemorrhage. They may also be associated with the migration of small residual microtraumatizing agent. The literature lacks algorithms for management in children.

DISCUSSION

In this paper, an unusual case of almost total sagittal cervical cord transection is reported. The patient had no neurological symptoms and recovered with no complications. Diagnostic imaging on admission included X-ray and computed tomography. The patient underwent early surgical intervention with removal of foreign body from the cord and subsequent dural suturing. In the paper, the role of detailed history taking, adequate imaging, and drugs administration is discussed. The choice of distinct strategies is analyzed, and a revised literature review is presented in order to unify the management algorithm for pediatric PSCI.

Neurologic sequelae of penetrating cervical trauma

STUDY DESIGN

Multicenter, retrospective chart analysis was performed using data housed in the trauma registries of 2 independent American College of Surgeons verified, Level I Trauma centers. The trauma registries were queried for all cases of penetrating cervical trauma. Abstracted data included age, sex, race, mechanism of injury, Glasgow Coma Scale (GCS) level on arrival, neurologic findings on arrival, zone of injury, associated injuries, imaging studies and results, operations performed, neurologic sequelae, disposition from the hospital and the presence or absence of neurologic injury, cervical spine fracture, and cervical spine immobilization.

OBJECTIVE

The purpose of this study was to determine the relationship between cervical spine immobilization and neurologic sequelae in penetrating cervical trauma.

SUMMARY OF BACKGROUND DATA

Current recommendations for cervical spine immobilization in penetrating cervical trauma developed by empiric extension of blunt trauma protocols without evidentiary support. No evidence exists to support cervical spine immobilization as a means of preventing neurologic injury progression in cases of penetrating cervical injury.

METHODS

Abstracted data were organized, entered into a database, and compared statistically. Significance was accepted for P<0.05.

RESULTS

A total of 196 patient charts formed the study cohort. Neurologic injuries either improved or remained static. No patient could be determined to have benefited from cervical spine immobilization in this study as the only 2 patients presenting with unstable cervical spine fractures were completely neurologically devastated at the time of injury. Prehospital cervical spine immobilization may have negatively affected patients with vascular and airway injuries. Decreased cervical spine immobilization rates at one institution did not affect neurologic outcome.

CONCLUSION

Cervical spine immobilization does not appear to prevent progression of neurologic injury in cases of penetrating cervical trauma. Comorbid penetrating injuries may be negatively impacted by prehospital cervical spine immobilization.

Increased risk of death with cervical spine immobilisation in penetrating cervical trauma

The purpose of this study was to determine if cervical spine immobilisation was related to patient mortality in penetrating cervical trauma. One hundred and ninety-nine patient charts from the Louisiana State University Health Sciences Center New Orleans (Charity Hospital, New Orleans) were examined. Charts were identified by searching the Charity Hospital Trauma Registry from 01/01/1994 to 04/17/2003 for all cases of penetrating cervical trauma. Thirty-five patient deaths were identified. Cervical spine immobilisation was associated with an increased risk of death (p<0.02, odds ratio 2.77, 95% CI 1.18-6.49).

Flexible esophagoscopy as a diagnostic tool for traumatic esophageal injuries

BACKGROUND

The management and clinical outcome of patients suffering esophageal trauma depends on a prompt diagnosis. The detection of esophageal injuries by clinical examination, esophagography, or computed tomography is limited. This study aimed to assess the yield and clinical utility of flexible esophagoscopy (FE) in the diagnosis of traumatic esophageal injuries.

PATIENTS

During 7 years, we conducted a retrospective (1998-2003) and prospective (2003-2005) study of 163 victims admitted to a trauma hospital, and submitted to FE because of suspected esophageal trauma. Esophageal injury was defined as laceration or perforation, hematoma, abrasion, hematin spots, or ecchymosis. The endoscopic diagnosis was compared with surgical findings or clinical follow-up.

RESULTS

No traumatic lesion was observed in 139 patients (85.3%), esophageal injuries were detected in 23 (14.1%), and one examination was inconclusive (esophageal stricture, 0.6%). Lacerations were detected in 14 patients and confirmed surgically. Esophageal contusion was observed in nine patients and out of these, five patients underwent surgical exploration and four were managed nonoperatively. The assessment of esophageal injury by FE demonstrated 95.8% sensitivity, 100% specificity, 99.3% accuracy, 100% positive predictive value, and 99.2% negative predictive value. The likelihood ratio for a negative examination was 0.041 and the Youden J Index was 99.2%.

CONCLUSIONS

FE appears to be an accurate diagnostic tool in the assessment of esophageal injuries. Two main lesions were noted: laceration and contusion. Laceration requires surgical repair. Contusion represents a nonperforative injury of the esophageal wall, requires correlation with computed tomography, and may be managed nonoperatively.

Tracheal trauma

The etiology, presentation, and management of blunt and penetrating injuries of the trachea has been reviewed. The approach to and outcome following management of more unusual situations such as iatrogenic injuries has also been briefly reviewed. Early recognition of these problems and careful attention to the details of acute management can convert a life-threatening situation into one that can usually be successfully managed by the techniques of tracheal surgery developed and popularized by Dr. Grillo.

Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study

OBJECTIVE

The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries.

METHODS

All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck.

RESULTS

During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry.

CONCLUSION

Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.

Practical points in evaluation and resuscitation of the injured child

The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.

Bedside diagnostic ultrasound and therapeutic ultrasound-guided procedures in the intensive care setting

The availability, portability, safety, and other features of ultrasound have ushered this relatively new imaging modality into the everyday clinical practice of multiple disciplines. Features unique to ultrasound lend this imaging modality the opportunity for extensive use in the ICU. A review of its uses in this capacity includes bedside diagnosis of common disorders seen in the ICU setting, such as DVT, cholecystitis, and abscess. Bedside sonography also can aid in the treatment of such disorders, including DGC of pseudoaneurysms, fluid aspirations, and abscess drainages. This article is a review and could not possibly cover all bedside uses of ultrasound or provide in-depth information of specific uses described in this article. Hopefully, this article will spark an interest and prove as a starting point on a rewarding learning adventure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE

To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries.

METHODS

The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed.

RESULTS

No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula.

CONCLUSIONS

Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.

Flexible endoscopy for the diagnosis of esophageal trauma

The role of flexible endoscopy in the diagnosis of esophageal trauma remains undefined. This study evaluates the use of immediate flexible fiberoptic esophagogastroduodenoscopy (EGD) as the primary diagnostic tool for detection of esophageal injury in trauma patients. Flexible EGD was performed on 31 patients for this purpose from August 1991 through January 1994. There were 28 males and 3 females with a mean age of 24.3 years (range, 16-54 years). Twenty-four of 31 patients (77%) were intubated at the time of the examination. Mechanism of injury was penetrating in 24 patients (20 gunshot wounds, four stab wounds) and blunt (motor vehicle crash) in seven patients. Penetrating injuries were located in the neck in 5 of 24 patients, in the chest in 15 of 24 patients, and in both the neck and chest in 4 of 24 patients. Upper gastrointestinal contrast studies were performed for 3 of 31 patients (10%), computed tomography was performed for eight patients (26%), bronchoscopy was performed for 13 patients (42%), angiography was performed for 17 patients (55%), and rigid esophagoscopy and laryngoscopy were each performed for one patient (3%). Evidence of esophageal trauma during EGD was seen in 5 of 31 patients. True-positive studies occurred for four patients, false-positive results occurred for one patient, true-negative results occurred for 26 patients (as demonstrated by exploration in five and clinical follow-up in 21), and no false-negative examinations occurred. Sensitivity of flexible EGD was 100%, specificity was 96%, and accuracy was 97%. No complications occurred related to the performance of EGD. Flexible fiberoptic endoscopy seems to be a safe and effective method for both detection and exclusion of esophageal trauma.

Chainsaw penetrating neck injury

A case of chainsaw injury to the neck is described. Previous reports in the English language are exceedingly rare. A brief discussion of safety features on chain saws is followed by a review of selective vs. mandatory surgical exploration in penetrating neck trauma, including the role of ancillary diagnostic tests.

Penetrating neck trauma in children: a reappraisal

The management of penetrating neck injuries in adults is controversial, with a trend toward selective neck exploration. These injuries are uncommon in children, and only limited information exists regarding their management. To assess the management of these injuries in the authors' geographic region, they reviewed the records of children with injuries penetrating the platysma muscle who were treated between 1980 and 1994. Forty-six children (aged 2 to 16 years) suffered a total of 55 penetrating neck injuries. The injuries were classified according to type and location. Fifty-two percent were caused by missiles, 30% by stab wounds, and 18% by dog bites. Fifty-eight percent of injuries were in zone II, 31% in zone I, and only 11% in zone III. The diagnostic workup, including arteriography, esophagography, or endoscopy, was performed preoperatively in 10 patients. Overall, 21 patients had exploration, and the rate of negative explorations was 48%. All cases explored for bleeding or a positive diagnostic workup result were found to have significant injury. On the other hand, all neck explorations performed solely because of injury to zone II were negative. The overall morbidity and mortality rates were 31% and 7%, respectively. A more selective approach, similar to that used for adult patients, emphasizing preoperative diagnostic evaluation, is recommended to decrease the rate of negative neck explorations among children.

Results of mandatory exploration for penetrating neck trauma

Management of penetrating wounds to the neck remains controversial despite decades of discussion in the literature. We assessed 393 consecutive stab wounds penetrating the platysma operated at our trauma service between January 14, 1991 and September 30, 1992 to evaluate our policy of mandatory neck exploration (NE). Injury to the common (n = 19 cases), external (n = 7), internal carotid (n = 5), innominate (n = 2), subclavian (n = 20), vertebral (n = 12), facial (n = 2), and intercostal (n = 2) arteries; the external (n = 36), internal (n = 65), subclavian (n = 20), and innominate (n = 4) veins; the pharynx/esophagus (n = 21); and the trachea (n = 28) was considered a positive NE (n = 167). 226 NEs were negative. Except for hemiparesis and bruit, the presence of clinical signs (shock, active hemorrhage, hematoma, surgical emphysema, dysphagia, blowing wound) did not predict a positive NE. Clinical signs were absent in 30% of positive NEs and in 58% of negative NEs. Complications of positive NE included wound infection (n = 7 cases), chyle drainage (n = 6), cerebellar stroke (n = 1), pneumonitis (n = 8), reoperation for recurrent hemorrhage (n = 1), subclavian artery graft occlusion (n = 1), bronchopleural fistula (n = 1), and cerebrospinal fluid leak (n = 1). Negative NEs were complicated by a wound infection in four cases and pneumonitis in one case. The mean hospital stay was 4.3 days for those with a positive NE and 1.5 days for those with a negative NE.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of penetrating wounds of the neck

Management policies for penetrating wounds of the neck vary from mandatory surgical exploration to selective surgical exploration following extensive or minimal imaging investigation. In order to review the treatment protocol at Sheba Medical Center, Tel Hashomer, Israel, we retrospectively studied 21 patients who were treated between the years 1984 and 1989. Thirteen had gunshot injuries and eight had stab wounds. Eight patients had undergone immediate exploration of the neck. Four patients had died, but all of these latter patients had evidence for significant bleeding that could have been detected within a short time of admission. On the basis of our findings and previous studies, we conclude that: presenting features of neck injuries should be differentiated into two basic categories: immediately life-threatening and not immediately life-threatening. Immediately life-threatening features include overt massive bleeding, expanding hematoma, non-expanding hematoma in the presence of hemodynamic instability, hemomediastinum, hemothorax, and hypovolemic shock. In all of these cases, immediate surgical exploration is mandatory. Non-life-threatening features include any signs of vascular complication in a hemodynamically stable patient, signs of upper aerodigestive tract lesions (when initial treatment has already relieved respiratory distress) and peripheral neurological deficits. These patients should undergo thorough imaging investigations on the basis of which the need for and the nature of possible surgical intervention can be determined.

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

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

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

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

Penetrating neck trauma: a 5-year review of the literature, 1983 to 1988

Penetrating neck trauma remains controversial: some trauma centers continue to pursue a policy of mandatory exploration while others advocate selective exploration. The literature regarding penetrating neck trauma published during the past 5 years is reviewed in this report. The majority of reports support selective exploration, and most civilian centers report a mortality of 3% to 6% regardless of the type of exploration performed. To clarify the rationale behind the selective management of penetrating neck wounds, current data on ballistics, ancillary diagnostic studies, and comparative costs are reviewed. Emergency room management and surgical follow-up, which vary according to the type of missile and the zone of the neck penetrated, are discussed.

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

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

Diagnosis of penetrating cervical esophageal injuries

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