Clinical practice guideline: penetrating zone II neck trauma

Surgical management of transcervical gunshot injury presented with CSF leak and progressive left upper extremity paresis: a case report and literature review

INTRODUCTION

Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality.

RESEARCH QUESTION

There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients.

METHODS AND MATERIALS

An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness.

RESULTS

The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up.

CONCLUSION

Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

Anterior Penetrating Neck Injury: A Path to the Cervical Spine

While rare in incidence, penetrating neck injuries are often life-threatening. When a patient's physiological status is appropriate, the first step in treatment should be a detailed preoperative imaging assessment. Formulating a treatment plan that includes computed tomography (CT) imaging and discussing the surgical approach with a multidisciplinary team before operating allows for a successful selective surgical approach. The authors report the case of a Zone II penetrating injury with a right laterocervical entry wound in which an impaled blade with an inferomedial oblique path pierced deeply into the cervical spine. The blade missed multiple vital structures in the neck, such as the common carotid artery, jugular vein, trachea, and esophagus. The patient underwent a formal neck exploration, and controlled extraction of the blade under direct vision was achieved. Therefore, the author's recommendation for implementing any management algorithm for penetrating neck injuries should rely primarily on a multidisciplinary selective approach.

Crossbow Bolt Penetrating the Neck Removed with the Assistance of an Endovascular Approach: A Case Report and Literature Review

Penetrating neck injury by a crossbow bolt is extremely rare and can be life-threatening. When removing a crossbow bolt from the neck, it is necessary to protect against fatal bleeding from the carotid vessels. We report removing a crossbow bolt penetrating the neck, with an endovascular approach. A 49-year-old woman was shot in the neck by a crossbow and was transferred to our hospital. On presentation, the crossbow bolt totally penetrated the neck from right to left. Her level of consciousness was clear, with no significant neurological deficits except for right peripheral facial palsy. Neck contrast-enhanced computed tomography revealed the crossbow bolt in contact with bilateral external and internal carotid arteries and that the bolt caused dissection of the left main trunk of the external carotid artery. Under general anesthesia, the crossbow bolt was removed under fluoroscopy with the assistance of an endovascular approach. First, we performed coil embolization for the dissected external carotid artery. Second, we prepared for fatal bleeding from the carotid arteries during crossbow bolt removal under protection using guiding catheters placed in bilateral common carotid arteries. The bolt was removed successfully without significant bleeding, and no complications occurred during the procedure. We report the successful removal of a crossbow bolt penetrating the neck. When removing a crossbow bolt penetrating the neck, endovascular assistance may be feasible to protect against fatal bleeding from the carotid arteries.

A successful surgical repair of a gunshot injury to the left common carotid artery without neurological deficiency: A case report

Introduction and importance

Penetrating neck trauma is serious and has a high fatality rate, especially in individuals who suffer injuries to the common carotid artery. The mortality rates for penetrating neck trauma are estimated to be 3%–6%. Accidents that cause a lot of blood to flow, like being stabbed, shot, or hurt in a car accident, can cause a person to lose a lot of blood quickly and in a short amount of time, which can be fatal if not treated right away.

Clinical presentation

we present a 26-year-old young male patient with penetrating neck trauma caused by a gunshot. The gunshot entered the right sternocleidomastoid muscle at the level of the hyoid bone and exited the left sternocleidomastoid muscle on the mid side.

Clinical discussion

In a recent report on the management of major vascular injuries to the neck, carotid artery injuries accounted for about 17% of all patients presenting with penetrating neck injuries. In this case, previously published literature adds that carotid artery injury early surgical and primary repair in young patients has a good outcome.

Conclusion

Considering the high morbidity and mortality associated with penetrating neck injuries, In young patients, they can be successfully managed with early surgical and primary repair with a good outcome.

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Mostly, carotid artery injuries are associated with neurological deficiency.

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The gold-standard approach for assessing suspected neck vascular damage is CT angiography.

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Carotid artery injury early primary surgical repair in young patients has a good outcome.

Protective Arteriovenous Fistula in Traumatic Common Carotid Transection

Penetrating injuries of the neck involving major vessels are associated with high morbidity and mortality. A traumatic arteriovenous (AV) fistula can provide a protective effect by decompressing the injured arterial structure and prevent massive blood loss and airway compression. We present a novel description of CCA (common carotid artery) transection with associated protective AV fistula. Protective AV fistulae have been uncommonly described, and to our knowledge, this is the first case involving carotid transection with associated protective AV fistula ultimately allowing lifesaving operative repair.

Trauma cervical penetrante: experiencia de un hospital de enseñanza en México

Introducción. El trauma cervical penetrante es una entidad poco frecuente, con tendencia al alza, de considerable morbimortalidad. Es fundamental conocer su manejo por cirujanos en entrenamiento, quienes en su mayoría son comúnmente los proveedores del tratamiento en las áreas de urgencias. El objetivo de este estudio fue demostrar la experiencia de un centro de trauma en México en el tratamiento de trauma cervical penetrante administrado por cirujanos en entrenamiento. Métodos. Estudio retrospectivo de pacientes con diagnóstico de trauma cervical penetrante sometidos a exploración cervical entre los años 2014 y 2019. Se identificaron 110 expedientes, se excluyeron 26 por falta de datos indispensables para la investigación y se analizaron los datos de 84 pacientes. Resultados. El 96,4 % de los pacientes fueron hombres, la mayoría entre 16 y 50 años (83,3 %) y la zona anatómica II fue la más comúnmente lesionada (65,4 %). Las etiologías más frecuentes fueron heridas por arma cortopunzante (67,9 %) y heridas por proyectil de arma de fuego (25 %). El 95 % de los procedimientos fueron realizados por residentes de cuarto y quinto año. La mediana de días de estancia hospitalaria fue de 2 días. La incidencia de complicaciones fue de 9,5 % y la mortalidad de 1,2 %. Conclusiones. Los cirujanos generales en etapa de formación entrenados en centros de trauma tienen la capacidad de tratar de forma óptima el trauma cervical penetrante sin modificación de las tasas de morbimortalidad descritas en la literatura internacional.

Penetrating injury with an arrow impacted in the neck in rural Tanzania, a case report

Introduction and importance

Penetrating neck injuries refer to neck injuries that penetrate through the platysma layer which can cause life-threatening injuries to the aerodigestive and neurovascular systems. Currently penetrating neck injuries are mainly due to modern firearms however penetrating neck injuries due to arrows are still seen, although rare, in rural areas among developing countries. Management depends on hemodynamic stability, signs of structural damage and zone of neck involved.

Case presentation

19-year-old male presenting with a penetrating arrow impacted in his neck following an attack by cattle raiders who was otherwise stable of presentation. Underwent preoperative imaging with removal of the arrow under general anaesthesia via surgical exploration.

Clinical discussion

We concur with the recommendation to first obtain adequate imaging to establish degree of injury as well as for operative planning. Removal of impacted arrow should not be carried out blindly but rather in a controlled environment under general anaesthesia via surgical exploration.

Conclusion

Penetrative arrow injuries to the neck are an archaic problem that can be dealt with via modern surgical principles towards penetrating neck injuries. Unstable patients warrant emergent exploration however stable patients can first be worked up appropriately to ascertain degree of injury. Impacted arrows can then be removed safely under general anaesthesia rather than risk further injury to critical structures via blind removal.

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Penetrating neck injury by an impacted arrow in rural countryside

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Application of surgical principles in penetrating neck injury due to an arrow

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Assessing relevant vascular anatomy via ultrasound due to financial constraints

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Successful surgical exploration and safe removal without postoperative complications

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Importance

The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators.

Objective

To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.

Design, Setting, and Participants

This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners.

Main Outcomes and Measures

Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability.

Results

Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery).

Conclusions and Relevance

In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Endovascular management of the post-traumatic common carotid artery pseudoaneurysms

Purpose

Pseudoaneurysms of the common carotid artery secondary to high-velocity fragment injuries to the head and neck in patients are uncommon lesions. Multi-detector computed tomography angiography should be performed on all patients suffering from high-speed fragment injuries of the head and neck.

Case presentation

We share our experience with the endovascular management approach for the closure of 2 separate pseudoaneurysms involving the left common carotid artery.

Conclusions

Numerous options for surgical and endovascular treatment of these lesions are available. Endovascular therapy in patients with common carotid artery pseudoaneurysms offers a reliable and non-invasive management option. It helps in the mitigation of its rupture and thromboembolic complications.

Thoracic esophageal injury due to a neck stab wound: a case report

BACKGROUND

Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade.

CASE PRESENTATION

A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries.

CONCLUSIONS

The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries

Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.

An Audit of Surgical Neck Explorations for Penetrating Neck Injuries in Northwestern Nigeria: Experience from a Teaching Hospital

Background:

Penetrating neck injury is a major trauma mechanism present in about 5%–10% of trauma patients with an estimated mortality of 3%–10%. The management of these injuries is dependent on the anatomical level of injury.

Objectives:

The objective of the study was to document the clinical and operative findings as well as the treatment outcome among our patients who underwent neck exploration for penetrating neck injuries.

Materials and Methods:

A retrospective review of patients who had neck exploration for penetrating neck injury between January 2012 and December 2018 was done.

Results:

Thirty-five patients all of whom had surgical neck exploration were included. The age ranged from 15 to 62 years with a male: female of 7.8:1. The mean age was 30.7 years with standard deviation of ± 12.5 years and the peak age of occurrence of 20–29 years. The mechanism of injury was commonly arrow injury in 9 (25.7%) and suicidal cutthroat in 7 (20%) patients. Thirty-two (91.4%) patients presented with stable vital signs. Zone II neck injuries were most prevalent, seen in 23 (65.7%) patients. Laryngeal injury in 7 (20%) and soft-tissue injury in 7 (20%) of the patients were the most common intraoperative findings. The complication rate of 17.1% with a mortality rate of 2.9% was recorded. There was a statistically significant association between the presence of vascular injury and the development of complications after exploration (Chi-square = 5.666, P = 0.017). It was also a significant positive predictor of complication following neck exploration (odds ratio = 0.017, P = 0.048).

Conclusion:

Male young adults were most involved, commonly from arrow and stab injuries. Although laryngeal and soft-tissue injuries were predominant, vascular injuries were most associated with postoperative complications.

'No zone' approach to the management of stable penetrating neck injuries: a systematic review

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.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach

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.

Penetrating Injury to the Carotid Artery: Characterizing Presentation and Outcomes from the National Trauma Data Bank

BACKGROUND

Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management.

METHODS

Data from the National Trauma Data Bank from 2002-2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching.

RESULTS

Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P < 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P < 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P < 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P < 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P < 0.001). There were no differences in outcomes relating to surgical approach.

CONCLUSIONS

These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient-for example, based on presenting characteristics and the location of the injury.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model

BACKGROUND

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate.

OBJECTIVES

We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT).

METHODS

Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded.

RESULTS

There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000).

CONCLUSIONS

The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Traumatic Penetrating Neck Injury with Right Common Carotid Artery Dissection and Stenosis Effectively Managed with Stenting: A Case Report and Review of the Literature

Introduction

Penetrating neck injuries (PNI) are common and associated with arterial and other neuronal injuries. Although many authors have written on penetrating and blunt carotid artery injuries as a result of PNI or traumatic neck injuries, no one has reported a case or case series on PNI that resulted in blunt carotid dissection and stenosis.

Case Presentation

We present a case of 40-year-old building and construction male worker who slipped and fell on an iron rod that resulted in penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He pulled out the iron rod immediately. Computer tomography angiography (CTA) done revealed C2-C4 transverse process fractures on the right side and a fracture at the right lamina of C3 and right common carotid artery dissection with stenosis. He was successfully treated with stenting via endovascular approach.

Conclusions

We adopt the view that patient should never pull out objects that result in PNI because of complex neurovascular architecture of the neck. The mortality rate of our patient will have doubled if the iron rode penetrated the common carotid artery. The gold standard treatment option for carotid artery dissection and stenosis is endovascular approaches.

Penetrating neck trauma caused by a rebar: A case report

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.

Defining and Measuring Decision-Making for the Management of Trauma Patients

BACKGROUND

Effective management of trauma patients is heavily dependent on sound judgment and decision-making. Yet, current methods for training and assessing these advanced cognitive skills are subjective, lack standardization, and are prone to error. This qualitative study aims to define and characterize the cognitive and interpersonal competencies required to optimally manage injured patients.

METHODS

Cognitive and hierarchical task analyses for managing unstable trauma patients were performed using qualitative methods to map the thoughts, behaviors, and practices that characterize expert performance. Trauma team leaders and board-certified trauma surgeons participated in semistructured interviews that were transcribed verbatim. Data were supplemented with content from published literature and prospectively collected field notes from observations of the trauma team during trauma activations. The data were coded and analyzed using grounded theory by 2 independent reviewers.

RESULTS

A framework was created based on 14 interviews with experts (lasting 1-2 hours each), 35 field observations (20 [57%] blunt; 15 [43%] penetrating; median Injury Severity Score 20 [13-25]), and 15 literary sources. Experts included 11 trauma surgeons and 3 emergency physicians from 7 Level 1 academic institutions in North America (median years in practice: 12 [8-17]). Twenty-nine competencies were identified, including 17 (59%) related to situation awareness, 6 (21%) involving decision-making, and 6 (21%) requiring interpersonal skills. Of 40 potential errors that were identified, root causes were mapped to errors in situation awareness (20 [50%]), decision-making (10 [25%]), or interpersonal skills (10 [25%]).

CONCLUSIONS

This study defines cognitive and interpersonal competencies that are essential for the management of trauma patients. This framework may serve as the basis for novel curricula to train and assess decision-making skills, and to develop quality-control metrics to improve team and individual performance.

Penetrating neck injuries: a guide to evaluation and management

Introduction Penetrating neck injury is a relatively uncommon trauma presentation with the potential for significant morbidity and possible mortality. There are no international consensus guidelines on penetrating neck injury management and published reviews tend to focus on traditional zonal approaches. Recent improvements in imaging modalities have altered the way in which penetrating neck injuries are now best approached with a more conservative stance. A literature review was completed to provide clinicians with a current practice guideline for evaluation and management of penetrating neck injuries. Methods A comprehensive MEDLINE (PubMed) literature search was conducted using the search terms 'penetrating neck injury', 'penetrating neck trauma', 'management', 'guidelines' and approach. All articles in English were considered. Articles with only limited relevance to the review were subsequently discarded. All other articles which had clear relevance concerning the epidemiology, clinical features and surgical management of penetrating neck injuries were included. Results After initial resuscitation with Advanced Trauma Life Support principles, penetrating neck injury management depends on whether the patient is stable or unstable on clinical evaluation. Patients whose condition is unstable should undergo immediate operative exploration. Patients whose condition is stable who lack hard signs should undergo multidetector helical computed tomography with angiography for evaluation of the injury, regardless of the zone of injury. Conclusions The 'no zonal approach' to penetrating neck trauma is a selective approach with superior patient outcomes in comparison with traditional management principles. We present an evidence-based, algorithmic and practical guide for clinicians to use when assessing and managing penetrating neck injury.

Contemporary Strategies in the Management of Civilian Neck Zone II Vascular Trauma

Neck trauma is the leading cause of death mainly in younger persons posing to surgeons the dilemma whether to proceed with reconstruction of vascular injuries either in the presence of coma or in severe neurological deficit. Vascular injuries in zone II predominate over the other injuries located in zones I/III of the neck. Conventional open repair of carotid injuries with primary closure or interposition grafting is always recommended due to the effective long-term results for penetrating injuries or for patients unfit for endovascular intervention. In cases of blunt trauma, anticoagulation or antiplatelet therapy should be administered first in neurologically stable patients. In case of worsening of the neurological status of the patient despite adequate anticoagulation endovascular means should be considered in cases of appropriate anatomy of the arterial trauma. We provide an update on penetrating/blunt trauma in zone II of the neck, giving emphasis on the anticoagulant and endovascular treatment.

"No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations

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.

Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures

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.

Evaluation of the use of tomography in penetrating neck trauma

OBJECTIVE

the study has the intention of evaluate the accuracy of computed tomography for the diagnosis of cervical lesions on penetrating neck trauma and also identify the most frequent mechanisms of trauma. Most injured structures, determine the age range and the most prevalent sex.

METHODS

observational descriptive retrospective study executed by the systematic retrospective review of medical records of all patients victims of penetrating neck trauma that went through surgery and CT scans, admitted into Hospital do Trabalhador, between January 2009 and December 2013.

RESULTS

the final sample was of 30 patients, 96.7% of the male sex, the median age was of 28 years old. Most patients suffered injuries by gun (56.7%) and 33,3% suffered stab wounds. The most stricken area of the neck was Zone II (77.8%) and the left side (55.2%). Regarding the structures injured, the CT showed 6.7% lesions on airways but the surgery showed 40% of damaged, with a value of p=0.002. As to damages of the esophagus and pharynx the CT detected 10% of lesions, while surgery found 30% of lesions, therefore with a significant value of p=0.013. As for the analysis the CT showed reliable. As for the analysis of vascular damage, the CT showed to be, in most cases, reliable to the findings during the surgical act.

CONCLUSION

besides the great use of CT for the diagnosis of penetrating neck injuries we can say that this is an exam with low accuracy for the diagnosis of lesions of aerodigestive tract, therefore it is important a clinical correlation for a good diagnosis.as for the vascular lesions and of other structures, the CT had high sensibility and specificity, thus a good exam to be used in overall.

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.

Decompressive craniectomy for massive internal carotid artery infarction after pediatric penetrating neck trauma

Pediatric penetrating carotid arterial trauma is a rare unreported cause of malignant cerebral infarction. Despite increasing evidence of benefit of decompressive hemicraniectomy (DCH) in pediatric malignant stroke, indications and predictors of outcome remain controversial. We report a 4-year-old boy with penetrating zone II neck trauma with laceration of the right internal carotid artery who developed malignant cerebral infarction requiring DCH. Impressive neurological recovery and excellent functional outcome was observed with good psychomotor development and quality of life. To our knowledge, this is the first reported case of pediatric malignant ICA infarction due to penetrating arterial trauma with good neurologic outcome after DCH.

Penetrating nontorso trauma: the head and the neck

Acute penetrating injuries to the head and neck cause considerable anxiety for most clinicians owing to concern for airway control and neurologic injury and to limited clinician experience in most centres. This article discusses an organized approach to the evaluation and initial treatment of penetrating injuries to the head and neck based on regional anatomy and clinical examination. The approach is particularly helpful in the context of ongoing hemorrhage and/or airway compromise.

Delayed presentation of deep penetrating trauma to the subaxial cervical spine

PURPOSE

To present a rare case of deep penetrating neck trauma in which a retained foreign body in the cervical spine (a broken knife blade) resulted in delayed radicular injury. We describe the surgical management using a retrojugular approach.

CASE REPORT

Our patient sustained a stab wound to the supraclavicular triangle from a small pocketknife. He was initially managed in a local hospital by simple primary wound closure without any radiological examinations, and was discharged home. The patient re-consulted in a delayed fashion with mild local persistent neck pain. Subsequent radiological investigations revealed a foreign body (the broken blade of a pocket knife) embedded in the left neural foramen between the C6 and C7 vertebrae penetrating the disc space. The blade was lying between the left C7 nerve root and the ipsilateral vertebral artery (VA) at the transition of V1 and V2 segments. Initial neurological evaluation was normal. Some days later, the patient developed a delayed left C7 radicular deficit. We undertook urgent exploration along the wound corridor through a retrojugular, transforaminal approach with successful removal of the blade.

DISCUSSION

To our knowledge, this is a unique case where a retained foreign body penetrated the soft tissues of the neck, embedding deep in the vertebral column without vascular, aerodigestive or significant primary neurological injury, while causing delayed neck pain and delayed onset radicular injury. We describe our surgical management for removal of the retained blade. The retrojugular approach gives excellent access to all of the important anatomical structures of the neck from an anterolateral approach.

Epidemiological survey of head and neck injuries and trauma in the United States

OBJECTIVE

Head and neck trauma results in a range of injuries, spanning minor lacerations to life-threatening airway compromise. Few studies provide in-depth analysis of injuries to the head and neck (HN). We aim to (1) describe HN injury prevalence in the US and (2) investigate patient disposition and the outcome of mortality.

STUDY DESIGN

Case series with chart review.

SETTING

Nationwide emergency department (ED) sample.

METHODS

The 2011 database was queried for encounters with a primary diagnosis of HN injury, as categorized by the Barell Injury Matrix. Weighted estimates for demographics, injury category, and mechanism were extracted. Predictors of mortality and admission were determined by multivariable regression.

RESULTS

We identified 131 million ED encounters. A weighted total of 5,418,539 visits were related to primary HN injuries. Average age was 30 (SE = 0.4), and 56.8% were male. Sixty-four percent of injuries were attributed to fall or blunt trauma. Open wounds comprised 41.8% of injuries. The most common procedure was laceration repair (70%). The majority of patients (97%) were discharged home. Mortality rate was less than 1%. Predictors of admission and mortality (P < .05) included multiple trauma, vessel trauma, and burns. Other risk factors included foreign-body, older age, and male gender.

CONCLUSIONS

Primary HN injuries commonly present to emergency rooms in the US. The majority of HN injuries are non-life threatening and do not require admission to the hospital or result in death. These data have implications for HN injury surveillance and may be used to risk-stratify patients who present with injuries in the acute care setting.

The management of accidental wire brush bristle ingestions: A combat military perspective

There has been an increasing recent trend in accidental ingestion of wire barbeque grill brush bristles. Because of the unique nature of the foreign object, both the diagnosis and management of this injury are new realms in everyday trauma without clearly established protocols. We present the case of an accidental wire bristle ingestion resulting in oesophageal perforation; with insight from recent military trauma data, we managed this patient conservatively without surgical exploration. In the subset of asymptomatic patients with negative imaging, this divergence from operative management is safe with close observation and follow-up.

Contemporary management of combat-related vertebral artery injuries

BACKGROUND

Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations.

METHODS

A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected.

RESULTS

Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy.

CONCLUSION

VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Perioperative anaesthetic management of penetrating neck injury associated with Rh blood type in a young adult

We describe here a young adult patient with penetrating neck injuries (PNI) with an Rh negative blood type and discuss the perioperative anaesthetic management of single-stage surgical exploration under general anaesthesia and extracorporeal circulation in this patient. The patient had zone II PNI and he was in a haemodynamically progressive unstable state, and the knife penetrated the left internal jugular vein, superior thyroid artery and recurrent laryngeal nerve; the trachea and the oesophagus were swelling at a rapid rate. Eight weeks after operation, the patient was discharged from the hospital without any complications.

The role of aerodigestive tract endoscopy in penetrating neck trauma

OBJECTIVE/HYPOTHESIS

To determine the role of aerodigestive tract endoscopy in the management of penetrating neck trauma.

STUDY DESIGN

Retrospective case series.

METHODS

A search of the hospital's trauma database was performed for patients who presented with penetrating neck trauma between July 1989 and June 2008. The mechanism and site of injury, airway status and manipulation, physical findings, diagnostic and therapeutic steps taken, and outcomes were all recorded.

RESULTS

One hundred sixty-three patients were identified. There were 144 males and 19 females. The mean age was 28 years (range, 13 to 65 years). There were 105 gunshot wounds, 9 shotgun injuries, and 48 stab wounds. Seventy-three patients (45%) underwent emergent neck exploration, of which 15 had upper aerodigestive tract injuries; intraoperative endoscopy was performed on 13 and was used to guide the repair. Ninety patients (55%) did not meet the criteria for emergent neck exploration. Endoscopy in this group was performed in symptomatic patients, which revealed two cases of unilateral true vocal fold motion impairment, one mucosal laceration of the right mainstem bronchus, one questionable area of injury at the apical segment of the right upper lobe bronchus, and one mucosal laceration of the proximal esophagus.

CONCLUSIONS

Aerodigestive tract endoscopy is critical in assessing and guiding surgical repair of injuries noted on surgical exploration. In stable patients with a low clinical suspicion of aerodigestive tract injury, it was of low yield. We propose a new algorithm for assessing aerodigestive tract injuries that includes multidetector computed tomography, in which only symptomatic patients who fail to meet the criteria for emergent neck exploration undergo endoscopy.

LEVEL OF EVIDENCE

4.

Outcomes from penetrating ballistic cervical injury

AIMS

Ballistic cervical injury has become a significant source of both morbidity and mortality for the deployed UK soldier. The aim of this paper was to document a case series of ballistic cervical wounds to describe the pattern of these injuries and relate them to outcome.

METHODS

The records of all UK service personnel sustaining wounds to the neck in Iraq or Afghanistan between 01 August 2004 and 01 January 2008 were analysed following identification by the Joint Theatre Trauma Registry. Blunt or thermal injuries were excluded.

RESULTS

The records of 75/76 service personnel sustaining penetrating cervical injury during this period were available for analysis. 56/75 (75%) were due to explosive fragmentation and the remainder due to gunshot wounds (GSW). 33/75 (44%) of soldiers sustained vascular injury, 32/75 (43%) injury to the spine or spinal cord, 29/75 (39%) injury to the larynx or trachea and 11/75 (15%) injury to the pharynx or oesophagus. 14/75 (19%) patients in this series underwent surgery in a hospital facility for treatment of potentially life threatening cervical injuries, with a survival rate after surgery of 12/14 (86%). The overall mortality from this series of battlefield penetrating neck injury was 63%.

CONCLUSIONS

Penetrating cervical ballistic injury is a significant source of injury to deployed UK service personnel, predominantly due to neurovascular damage. Neck collars if worn would likely prevent many of the injuries in this case series but such protection is uncomfortable and may interfere with common military tasks. Newer methods of protecting the neck should be investigated that will be acceptable to the deployed UK soldier.