1
|
Shiroff AM, Gale SC, Martin ND, Marchalik D, Petrov D, Ahmed HM, Rotondo MF, Gracias VH. Penetrating Neck Trauma: A Review of Management Strategies and Discussion of the ‘No Zone’ Approach. Am Surg 2020; 79:23-9. [DOI: 10.1177/000313481307900113] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck “zones” to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called “selective approach.” Currently, modern sensitive imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a “No Zone” paradigm: an evidence-based method eliminating “neck zone” differentiation during triage and management. We conclude that a comprehensive physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical examination and CTA.
Collapse
Affiliation(s)
- Adam M. Shiroff
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Stephen C. Gale
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Niels D. Martin
- Department of Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Marchalik
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Dmitriy Petrov
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Hesham M. Ahmed
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Michael F. Rotondo
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Vicente H. Gracias
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| |
Collapse
|
2
|
Brigode WM, Masteller M, Chaudhuri R, Sullivan R, Vafa A. Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities. Am Surg 2018. [DOI: 10.1177/000313481808400853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.
Collapse
Affiliation(s)
- William M. Brigode
- From the Trauma/Critical Care Division, Department of Surgery, University of Illinois at Chicago - Mount Sinai Hospital Chicago, Illinois
| | - Michael Masteller
- From the Trauma/Critical Care Division, Department of Surgery, University of Illinois at Chicago - Mount Sinai Hospital Chicago, Illinois
| | - Rishi Chaudhuri
- From the Trauma/Critical Care Division, Department of Surgery, University of Illinois at Chicago - Mount Sinai Hospital Chicago, Illinois
| | - Ryan Sullivan
- From the Trauma/Critical Care Division, Department of Surgery, University of Illinois at Chicago - Mount Sinai Hospital Chicago, Illinois
| | - Amir Vafa
- From the Trauma/Critical Care Division, Department of Surgery, University of Illinois at Chicago - Mount Sinai Hospital Chicago, Illinois
| |
Collapse
|
3
|
Abstract
Laryngeal trauma is an uncommon but life threatening injury which is uncommon in British practice. It often occurs as part of a multiple injury. Major laryngeal injury may cause catastrophic airway compromise and death. Minor laryngeal injuries may be missed as more severe injuries supercede the management of the larynx. This may have adverse long-term sequlae. This article presents the initial assess ment and management of the patient with laryngeal trauma. The various controversies are discussed with reference to the literature available. The surgical approaches to the larynx are described.
Collapse
Affiliation(s)
| | - P Pracy
- Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
4
|
Madsen AS, Laing GL, Bruce JL, Clarke DL. A comparative audit of gunshot wounds and stab wounds to the neck in a South African metropolitan trauma service. Ann R Coll Surg Engl 2016; 98:488-95. [PMID: 27269237 PMCID: PMC5210006 DOI: 10.1308/rcsann.2016.0181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2015] [Indexed: 11/22/2022] Open
Abstract
Introduction The aim of this comparative study of gunshot wounds (GSWs) and stab wounds (SWs) to the neck was to quantify the impact of the mechanism of injury on the outcome and management of penetrating neck injury (PNI). Methods A prospective trauma registry was interrogated retrospectively. Data were analysed pertaining to demographics and injury severity score (ISS), physiology on presentation, anatomical site of wounds and injuries sustained, investigations, management, outcome and complications. Results There were 452 SW and 58 GSW cases over the 46 months of the study. Patients with GSWs were more likely to have extracervical injuries than those with SWs (69% vs 63%). The incidence of a 'significant cervical injury' was almost twice as high in the GSW cohort (55% vs 31%). For patients with transcervical GSWs, this increased to 80%. The mean ISS was 17 for GSW and 11 for SW patients. Those in the GSW cohort presented with threatened airways and a requirement for an emergency airway three times as often as patients with SWs (24% vs 7% and 14% vs 5% respectively). The incidence among GSW and SW patients respectively was 5% and 6% for airway injuries, 12% and 8% for injuries to the digestive tract, 21% and 16% for vascular injuries, 59% and 10% for associated cervical injuries, 36% and 14% for maxillofacial injuries, 16% and 9% for injuries to the head, and 35% and 45% for injuries to the chest. In the GSW group, 91% underwent computed tomography angiography (CTA), with 23% of these being positive for a vascular injury. For SWs, 74% of patients underwent CTA, with 17% positive for a vascular injury. Slightly more patients with GSWs required operative intervention than those with SWs (29% vs 26%). Conclusions Patients with GSWs to the neck have a worse outcome than those with injuries secondary to SWs. However, the proportion of neck injuries actually requiring direct surgical intervention is not increased and most cases with PNI secondary to GSWs can be managed conservatively with a good outcome. Imaging should be performed for all GSWs to the neck.
Collapse
Affiliation(s)
- A S Madsen
- University of KwaZulu-Natal , South Africa
| | - G L Laing
- University of KwaZulu-Natal , South Africa
| | - J L Bruce
- University of KwaZulu-Natal , South Africa
| | - D L Clarke
- University of KwaZulu-Natal , South Africa
| |
Collapse
|
5
|
Strumwasser A, Chong V, Chu E, Victorino GP. Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest. Injury 2016; 47:2000-5. [PMID: 27324324 DOI: 10.1016/j.injury.2016.05.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 05/02/2016] [Accepted: 05/28/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). METHODS A ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. RESULTS A total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. CONCLUSIONS Thoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.
Collapse
Affiliation(s)
- Aaron Strumwasser
- University of California, San Francisco-East Bay, Department of Surgery, 1411 East 31st Street, Oakland, CA, United States.
| | - Vincent Chong
- University of California, San Francisco-East Bay, Department of Surgery, 1411 East 31st Street, Oakland, CA, United States.
| | - Eveline Chu
- University of California, San Francisco-East Bay, Department of Surgery, 1411 East 31st Street, Oakland, CA, United States
| | - Gregory P Victorino
- University of California, San Francisco-East Bay, Department of Surgery, 1411 East 31st Street, Oakland, CA, United States.
| |
Collapse
|
6
|
Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries. J Trauma Acute Care Surg 2016; 79:1089-95. [PMID: 26680145 DOI: 10.1097/ta.0000000000000772] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.
Collapse
|
7
|
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.
Collapse
Affiliation(s)
- C A Burgess
- Department of ENT Surgery, The Royal Berkshire Hospital, Reading, UK.
| | | | | | | |
Collapse
|
8
|
Abstract
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.
Collapse
|
9
|
Affiliation(s)
- Lindsey A Nelson
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0764, USA.
| |
Collapse
|
10
|
Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury 2007; 38:48-52. [PMID: 17054956 DOI: 10.1016/j.injury.2006.07.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 07/17/2006] [Accepted: 07/24/2006] [Indexed: 02/02/2023]
Abstract
AIM The purpose of this study was to review and evaluate the efficacy of contrast-enhanced helical computed tomographic (CT) scanning in evaluating potential mediastinal injuries in stable patients with transmediastinal gunshot wounds (TMGSWs). METHODS During the review period, 01 January 2002-31 May 2005, the medical records of all haemodynamically stable patients with TMGSWs were retrieved and reviewed for demographics, diagnostic workup, treatment and complications. Screening CT was considered inconclusive in the presence of a mediastinal haematoma, pneumomediastinum or a missile track in proximity of major mediastinal structures. Inconclusive CT scans were further evaluated with angiography, and/or oesophography, and/or cardiac ultrasound. RESULTS Fifty consecutive haemodynamically stable patients with TMGSWs were identified. Thirty-five CT scans were performed, of which 29 (82.9%) were conclusive. Further diagnostic evaluation in the remaining six patients showed no injury. All patients were observed in a high-care unit and there were no missed injuries. The hospital charges generated with the CT scan based protocol were significantly less than with standard evaluation. CONCLUSION Contrast enhanced helical CT scanning is a safe, efficient and cost effective screening tool for evaluating haemodynamically stable patients with TMGSWs.
Collapse
Affiliation(s)
- Sheriff Ibirogba
- Trauma Centre C-14, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | | | | |
Collapse
|
11
|
Smakman N, Nicol AJ, Walther G, Brooks A, Navsaria PH, Zellweger R. Factors affecting outcome in penetrating oesophageal trauma. Br J Surg 2004; 91:1513-9. [PMID: 15386317 DOI: 10.1002/bjs.4760] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Penetrating oesophageal trauma is rare and the risk factors affecting outcome have not been clearly identified. Delayed management has been cited as a factor contributing to the high rates of morbidity and mortality, but evidence for this is lacking.
Methods
A retrospective study was undertaken of patients with penetrating oesophageal trauma presenting to a level I trauma centre over 8 years. Outcome was assessed in terms of mortality, morbidity (oesophageal and non-oesophageal), and length of hospital and intensive care unit (ICU) stays.
Results
Fifty-two patients with oesophageal injury who reached the operating theatre were included. The overall mortality rate was 6 per cent. Fifteen patients (29 per cent) developed oesophageal injury-related complications. Time from injury to management was the only important risk factor for the development of oesophageal complications (P = 0·001), but did not affect the length of ICU (P = 0·560) or hospital (P = 0·329) stay, incidence of non-oesophageal injury-related complications (P = 0·963) or death (P = 0·937). Patients with gunshot injuries spent longer in the ICU (P = 0·007) and the duration of hospital stay was longer for those with higher-grade oesophageal injuries (P = 0·025).
Conclusion
The risk of oesophageal injury-related complications was directly related to the interval between the trauma and definitive management of the oesophageal injury.
Collapse
Affiliation(s)
- N Smakman
- Department of Surgery, Trauma Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | |
Collapse
|
12
|
Abstract
OBJECTIVES (1) To determine the actual incidence of transmural pharyngeal and oesophageal injuries (POI); (2) to reveal the main causes and character of infectious complications following transmural POI; (3) to evaluate the effectiveness of different types of urgent surgical intervention for complicated transmural POI. METHODS A detailed retrospective analysis was completed on 15 years (1987-2001) of clinical experience, involving 84 cases of POI, caused by neck or chest injuries, foreign bodies, tracheal intubation, oesophagogastroscopy and oesophageal dilation (bougienage). RESULTS Transmural (perforating) and superficial (non-perforating) POI were revealed in 58 and 26 cases, respectively. Transmural POI was diagnosed within 24h in 38 of the 58 patients. Fourteen patients with uncomplicated transmural POI were treated conservatively; all recovered uneventfully. Forty-two patients with complicated transmural POI underwent urgent surgical intervention. Hospital stay was shorter in patients who underwent primary repair of the perforated pharyngeal or oesophageal wall than in those who had only irrigational drainage ( 22.4 +/- 5.3 days versus 31.7 +/- 8.4 days). Overall post-operative morbidity and mortality were 42.8 and 19.0%, respectively. CONCLUSIONS (1) Transmural injuries occurred in approximately two-third of the total number of POI; (2) underlying pathology, location of injury, time to accurate diagnosis and, eventually, urgent surgical intervention constituted statistically significant influences ( P < 0.05) relevant to development of complications following transmural POI; (3) urgent surgical intervention is the main part of the combined treatment of complicated transmural POI.
Collapse
Affiliation(s)
- Romaldas Rubikas
- Thoracic Surgery Clinic of Kaunas Medical University Hospital (Kauno Medicinos Universiteto Torakalinës chirurgijos klinika), Eiveniu 2, Kaunas 3007, Lithuania.
| |
Collapse
|
13
|
Atkins BZ, Abbate S, Fisher SR, Vaslef SN. Current management of laryngotracheal trauma: case report and literature review. ACTA ACUST UNITED AC 2004; 56:185-90. [PMID: 14749588 DOI: 10.1097/01.ta.0000082650.62207.92] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- B Zane Atkins
- Department of Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, San Antonio, TX 78236-5300, USA.
| | | | | | | |
Collapse
|
14
|
Abstract
The introduction of CT imaging in the 1970s revolutionized all aspects of medical care, perhaps nowhere more so than in the evaluation of acutely injured patients. Just as single-slice helical scanning was a great advance over conventional CT, the capabilities of MSCT are proving to be dramatically superior to single-slice methods. Improved contrast bolus imaging, thinner slices, and isotropic voxels should enable the trauma radiologist to identify both major organ system disruption and subtle injuries more promptly. Multiplanar and three-dimensional reconstructions, a forte of MSCT, facilitate rapid communication of disease states with surgeons and others involved in the care of injured patients. In many centers, whole-body CT is beginning to supplant plain films of the chest and spine in the evaluation of severe trauma victims; the cost-effectiveness of such methods is still under evaluation.
Collapse
Affiliation(s)
- Luis A Rivas
- Department of Radiology, University of Miami School of Medicine, Jackson Memorial Hospital, West Wing 279, 1611 Northwest 12th Avenue, Miami, FL 33136, USA
| | | | | | | |
Collapse
|
15
|
van As AB, van Deurzen DFP, Verleisdonk EJMM. Gunshots to the neck: selective angiography as part of conservative management. Injury 2002; 33:453-6. [PMID: 12095728 DOI: 10.1016/s0020-1383(02)00056-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Trauma units all over the world are faced with an ever-increasing number of gunshot injuries. While the traditional view is that exploration is mandatory for all gunshot wounds to the neck, this issue is now often debated amongst trauma surgeons. The aim of this particular study was to assess the outcome of gunshot wounds to the neck using a selective conservative approach. Haemodynamically stable patients were investigated with angiography. Only when this proved to be positive, the patient was surgically explored. The records of 116 patients presenting with a gunshot to the neck to our trauma unit over a 3-year-period were reviewed. We studied demographics, bullet track, clinical findings, diagnostic investigations, methods of treatment, time in hospital and outcome. Seventy of the 116 patients sustained a direct hit to the neck, in 46 patients the bullet traversed the face or chest first. Eighty-five patients presented with vascular injury, 61 with an injury to the airway, 32 with an injury to the pharynx or oesophagus, and 12 with sustained neurological damage. Angiography was performed in 89 patients and was positive in 12 patients. Lesions occurred in the common carotid artery (seven), the internal carotid artery (three), the external carotid artery (three), the vertebral artery (two) and the subclavian artery (one). Five patients had more than one lesion. In total 18 patients were treated operatively by performing a neck exploration. Four patients had emergency surgery for exsanguinating bleed. Fourteen had surgery after a positive diagnostic study; 12 after angiography, 2 after another positive investigation. Ten (8.6%) patients died; three during resuscitation, three during emergency exploration, two due to respiratory failure, one postoperative and one from the adult respiratory distress syndrome (ARDS). Our results suggest that selective conservative management is a good treatment for gunshot wounds of the neck. In our experience angiography plays a key role in the detection of a major vascular injury requiring surgical exploration. Careful clinical assessment enhanced with the appropriate investigations is the cornerstone for deciding to explore a gunshot wound to the neck.
Collapse
Affiliation(s)
- A B van As
- Trauma Unit, Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Groote Schuur Hospital, Rondebosch, 7701 Cape Town, South Africa.
| | | | | |
Collapse
|
16
|
Abstract
The evaluation of mediastinal trauma has undergone some important changes in the last few years. Electrocardiography (ECG) combined with troponin measurements have become the standard of evaluation of suspected blunt cardiac trauma. Spiral computerized tomography (CT) scan has largely replaced angiography for suspected blunt aortic rupture. There is good evidence that with a suspicious mechanism of injury the thoracic aorta should be evaluated irrespective of chest X-ray findings. In penetrating trauma the introduction of trauma ultrasound in the emergency room has revolutionized the early diagnosis of cardiac tamponade. Most mediastinal gunshot wounds in haemodynamically stable patients can safely be managed non-operatively. Evaluation of the direction of the bullet tract by means of spiral CT scan has replaced angiography and oesophageal studies in about 75% of patients with mediastinal gunshot wounds who are haemodynamically stable.
Collapse
Affiliation(s)
- Ali Salim
- Department of Surgery, Division of Trauma and Critical Care, University of Southern California School of Medicine and the Los Angeles County and University of Southern California Medical Center, Los Angeles, CA 90033, USA
| | - Demetrios Demetriades
- Department of Surgery, Division of Trauma and Critical Care, University of Southern California School of Medicine and the Los Angeles County and University of Southern California Medical Center, Los Angeles, CA 90033, USA,
| |
Collapse
|
17
|
Hanpeter DE, Demetriades D, Asensio JA, Berne TV, Velmahos G, Murray J. Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds. THE JOURNAL OF TRAUMA 2000; 49:689-94; discussion 694-5. [PMID: 11038087 DOI: 10.1097/00005373-200010000-00017] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies. METHODS This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued. RESULTS A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan. CONCLUSION The helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.
Collapse
Affiliation(s)
- D E Hanpeter
- Department of Surgery, Los Angeles County--University of Southern California, USA
| | | | | | | | | | | |
Collapse
|
18
|
Abstract
BACKGROUND Transmediastinal gunshot injuries are a rarely reported injury. Until recently, assessment of the thoracic aorta by angiography preceded the investigation of the esophagus. This order has been recently debated. METHODS There were 118 patients with potential transmediastinal injuries included in this retrospective study. Unstable patients who were unresponsive to resuscitation were taken to the operating room without previous investigation. Stable patients were routinely investigated initially for injury of the aorta and then for injury of the esophagus. RESULTS There were 51 patients who underwent urgent thoracotomy/sternotomy. In 27, the hemorrhage was of mediastinal origin; 17 of these patients died of intraoperative bleeding. Eight of the patients had aortic injury, and only one of this group survived. There were 57 stable patients who were investigated initially for injury of the aorta by angiography. It was positive in only one patient who underwent an operation with good results. An investigation of the esophagus followed and revealed esophageal injury in 17 patients. All of them were treated operatively, 15 of them with satisfactory outcome. CONCLUSIONS Angiography should at present precede esophageal investigations. There is a need for shortening the time between admission and operation. Other modalities that could expedite the investigation of the thoracic aorta and the esophagus should be prospectively evaluated in multi-center studies.
Collapse
Affiliation(s)
- E Degiannis
- Department of Surgery, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.
Collapse
Affiliation(s)
- S D LeBlang
- Department of Radiology, University of Miami/Jackson Memorial Hospital, Florida 33136, USA.
| | | |
Collapse
|
20
|
Renz BM, Cava RA, Feliciano DV, Rozycki GS. Transmediastinal gunshot wounds: a prospective study. THE JOURNAL OF TRAUMA 2000; 48:416-21; discussion 421-2. [PMID: 10744278 DOI: 10.1097/00005373-200003000-00008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation. METHODS A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg. RESULTS The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation. CONCLUSION The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.
Collapse
Affiliation(s)
- B M Renz
- Gwinnett Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | | |
Collapse
|
21
|
|
22
|
Grossman MD, May AK, Schwab CW, Reilly PM, McMahon DJ, Rotondo M, Shapiro MB, Kauder DR, Frankel H, Anderson H. Determining anatomic injury with computed tomography in selected torso gunshot wounds. THE JOURNAL OF TRAUMA 1998; 45:446-56. [PMID: 9751533 DOI: 10.1097/00005373-199809000-00004] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.
Collapse
Affiliation(s)
- M D Grossman
- Department of Surgery, University of Pennsylvania, Philadelphia, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|