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Madsen AS, Kruger D, Clarke DL, Navsaria P, Scriba M, Bekker W, Moeng MS. Outcomes of penetrating carotid artery injuries: A South African multicentre study. World J Surg 2024; 48:1848-1862. [PMID: 38922735 DOI: 10.1002/wjs.12252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. METHODS Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. RESULTS Of 149 identified patients, 137 actively managed patients were included. Twenty-four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). CONCLUSIONS Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries.
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Affiliation(s)
- Andre Steiner Madsen
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Deirdre Kruger
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Damian Luiz Clarke
- Department of Surgery Pietermaritzburg, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Pradeep Navsaria
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Matthias Scriba
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Wanda Bekker
- Department of Surgery Pietermaritzburg, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Maeyane Steve Moeng
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Siletz A, Inaba K. Diagnostic approach to penetrating neck trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:175-182. [PMID: 38523116 DOI: 10.1097/ta.0000000000004292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Anaar Siletz
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (A.S., K.I.), Los Angeles General Medical Center; and Keck School of Medicine (A.S., K.I.), University of Southern California, Los Angeles, California
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Singh S. Delayed Surgical Intervention in Cranio-Maxillofacial Splinter Injury: Report of a Case and A Literature Review. J Maxillofac Oral Surg 2024; 23:394-401. [PMID: 38601233 PMCID: PMC11001846 DOI: 10.1007/s12663-023-02061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/07/2023] [Indexed: 04/12/2024] Open
Abstract
Introduction In the context of Indian combat scenario, maxillofacial injuries from gunshots are uncommon. Methods The first section of this study is a case report of a rare instance of metal foreign bodies that were lodged in the parapharyngeal space, deeper to the deep lobe of the parotid right next to the carotid space in the neck. The second section focusses on the unique treatment for blast injuries as well as the variety of imaging procedures that are readily available to assist with surgery, such as plain film, CT, angiography, and occasionally MR imaging. Result and Conclusion According to the study, understanding the pertinent anatomy, precise imaging of the penetrating object in relation to vital structures, meticulously planned and conducted surgical removal of the foreign body, and repair of damaged structures are the key elements of a successful treatment.
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Affiliation(s)
- Shagun Singh
- Department of Oral and Maxillofacial Surgery, 3 Corps Dental Unit, Armed Forces, Dimapur, India
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Hamilton JM, Chan TG, Moore CE. Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols. Otolaryngol Clin North Am 2023; 56:1013-1025. [PMID: 37353366 DOI: 10.1016/j.otc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.
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Affiliation(s)
- James M Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Tyler G Chan
- Emory University School of Medicine, Atlanta, GA, USA
| | - Charles E Moore
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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Rodríguez-Ramos A, Zapata-Castilleja CA, Treviño-González JL, Palacios-Saucedo GC, Sánchez-Cortés RG, Hinojosa-Amaya LG, Nieto-Sanjuanero A, de la O-Cavazos M. Frontal penetrating arrow injury: A case report. World J Clin Cases 2023; 11:4117-4122. [PMID: 37388790 PMCID: PMC10303610 DOI: 10.12998/wjcc.v11.i17.4117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Penetrating arrow injuries of the head and neck are exceedingly rare in pediatric patients. This pathology has high morbidity and mortality because of the presence of vital organs, the airway, and large vessels. Therefore, the treatment and removal of an arrow is a challenge that requires multidisciplinary management.
CASE SUMMARY A 13-year-old boy was brought to the emergency room after an arrow injury to the frontal region. The arrowhead was lodged in the oropharynx. Imaging studies showed a lesion of the paranasal sinuses without compromising vital structures. The arrow was successfully removed by retrograde nasoendoscopy without complications, and the patient was discharged.
CONCLUSION Although rare, maxillofacial arrow injuries have high morbidity and mortality and require multidisciplinary management to preserve function and aesthetics.
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Affiliation(s)
- Alejandra Rodríguez-Ramos
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Carlos A Zapata-Castilleja
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - José L Treviño-González
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Gerardo C Palacios-Saucedo
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Ramón G Sánchez-Cortés
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Leonor G Hinojosa-Amaya
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Adriana Nieto-Sanjuanero
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
| | - Manuel de la O-Cavazos
- Department of Pediatrics, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey 64460, Nuevo León, Mexico
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Witt CE, Sumislawski JJ, Burlew CC. Natural history and nonoperative management of penetrating cerebrovascular injury. Injury 2023; 54:131-137. [PMID: 36376123 DOI: 10.1016/j.injury.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION There is a modern precedent for nonoperative management of select penetrating cerebrovascular injuries (PCVIs); however, there is minimal data to guide management. PATIENTS AND METHODS This study assessed treatments, radiographic injury progression, and outcomes for all patients with PCVIs managed at an urban Level I trauma center from 2016 to 2021 that underwent initial nonoperative management (NOM). RESULTS Fourteen patients were included. There were 11,635 trauma admissions, 378 patients with blunt cerebrovascular injury, and 18 patients with operatively-managed PCVI during this timeframe. All patients received antithrombotic therapy, but this was delayed in some due to concomitant injuries. Three patients had stroke (21%): two before antithrombotic initiation, and one with unclear timing relative to treatment. Three patients underwent endovascular interventions. On follow-up imaging, 14% had injury resolution, 36% were stable, 21% worsened, and 29% had no follow-up vascular imaging. One patient died (7%), one had a bleeding complication (7%), and no patient required delayed operative intervention. DISCUSSION Early initiation of antithrombotic therapy, early surveillance imaging, and selective use of endovascular interventions are important for nonoperative management of PCVI.
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Affiliation(s)
- Cordelie E Witt
- Department of Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA.
| | - Joshua J Sumislawski
- Department of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Aurora, CO 80045, USA
| | - Clay Cothren Burlew
- Department of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Aurora, CO 80045, USA
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Goldstein LN, Dawadi S, Viljoen IM. CT Utilization in a Level One Trauma Center in South Africa. Cureus 2022; 14:e29041. [PMID: 36249666 PMCID: PMC9550209 DOI: 10.7759/cureus.29041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Computed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging. Methods This was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department’s picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate. Results There were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan. Conclusions South Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting.
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Kong V, Cheung C, Ko J, Xu W, Bruce J, Liang G, Manchev V, Clarke D. The Management of Penetrating Neck Injury With Retained Knife: 15-Year Experience From a Major Trauma Center in South Africa. Am Surg 2021; 88:2703-2709. [PMID: 34965158 DOI: 10.1177/00031348211065127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study reviews our cumulative experience with the management of patients presenting with a retained knife following a penetrating neck injury (PNI). METHODS A retrospective cohort study was conducted at a major trauma center in South Africa over a 15-year period from July 2006 to December 2020. All patients who presented with a retained knife in the neck following a stab wound (SW) were included. RESULTS Twenty-two cases were included: 20 males (91%), mean age: 29 years. 77% (17/22) were retained knives and 23% (5/22) were retained blades. Eighteen (82%) were in the anterior neck, and the remaining 4 cases were in the posterior neck. Plain radiography was performed in 95% (21/22) of cases, and computed tomography (CT) was performed in 91% (20/22). Ninety-five percent (21/22) had the knife or blade extracted in the operating room (OR). Formal neck exploration (FNE) was undertaken in 45% (10/22) of cases, and the remaining 55% (12/22) underwent simple extraction (SE) only. Formal neck exploration was more commonly performed for anterior neck retained knives than the posterior neck, although not statistically significant [56% (10/18) vs 0% (0/18), P = .096]. There were no significant differences in the need for intensive care admission, length of hospital stay, morbidities, or mortalities between anterior and posterior neck retained knives. DISCUSSION Uncontrolled extraction of a retained knife in the neck outside of the operating room may be dangerous. Retained knives in the anterior neck commonly required formal neck exploration but not for posterior neck retained knives.
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Affiliation(s)
- Victor Kong
- Department of Surgery, 37707University of the Witwatersrand, Johannesburg, South Africa
| | - Cynthia Cheung
- Department of Surgery, 118838Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Jonathan Ko
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - William Xu
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - John Bruce
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Grant Liang
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Vasil Manchev
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, 37707University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
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9
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Paladino L, Baron BJ, Shan G, Sinert R. Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review. Acad Emerg Med 2021; 28:1160-1172. [PMID: 34021515 DOI: 10.1111/acem.14298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.
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Affiliation(s)
- Lorenzo Paladino
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Bonny J. Baron
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Gururaj Shan
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Richard Sinert
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
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Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg 2021; 89:1233-1238. [PMID: 32890346 DOI: 10.1097/ta.0000000000002919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT. METHODS We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017. RESULTS A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%. CONCLUSIONS This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients. LEVEL OF EVIDENCE Systematic review, level IV.
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Chandrananth ML, Zhang A, Voutier CR, Skandarajah A, Thomson BNJ, Shakerian R, Read DJ. 'No zone' approach to the management of stable penetrating neck injuries: a systematic review. ANZ J Surg 2021; 91:1083-1090. [PMID: 33480177 DOI: 10.1111/ans.16600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aim: to review outcomes of the 'no zone' approach to penetrating neck injuries (PNIs) with the advent of high-fidelity computed tomography-angiography (CT-A) in order to determine the most appropriate management for stable PNIs. DESIGN Systematic review. POPULATION Retrospective and prospective cohort studies of patients who sustained penetrating neck trauma, as defined by an injury which penetrates the platysma, and whose initial management involved CT-A evaluation. METHODS An extensive literature search was performed in July 2019 using the following databases: Pubmed Central, EMBASE, Medline and Cochrane CENTRAL. Only studies published in English from the last 15 years were included. RESULTS Nine cohort studies met inclusion criteria. There has been an increase in CT-A focussed evaluation of PNIs in recent years. CT-A is a highly sensitive and specific imaging choice and reduces negative neck exploration rates. A new management algorithm for stable patients involving initial radiological assessment using CT-A, and subsequent selective surgical exploration, is safe and effective. CONCLUSION The results of this review provide level 2A evidence that the 'no zone' approach to PNIs, complemented by CT-A and thorough clinical assessment, is a safe management strategy which reduces negative neck exploration rates.
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Affiliation(s)
- Meera L Chandrananth
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew Zhang
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Catherine R Voutier
- Health Sciences Library, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anita Skandarajah
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rezvaneh Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David J Read
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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12
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Christian AB, Maithel S, Grigorian A, Kabutey NK, Dolich M, Kong A, Gambhir S, Sheehan BM, Nahmias J. Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury. Ann Vasc Surg 2020; 72:440-444. [PMID: 32949747 DOI: 10.1016/j.avsg.2020.08.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected. METHODS The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality. RESULTS A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95). CONCLUSIONS The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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Affiliation(s)
- Ashton B Christian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Shelley Maithel
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Matthew Dolich
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Allen Kong
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA.
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Madsen AS, Bruce JL, Oosthuizen GV, Bekker W, Smith M, Manchev V, Laing GL, Clarke DL. Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach. BJS Open 2020; 4:704-713. [PMID: 32525254 PMCID: PMC7397367 DOI: 10.1002/bjs5.50282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a ‘no‐zone’ approach to PNI is valid. Methods Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared. Results In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination. Conclusion An approach to PNI based on zones is questionable, and this study supports a no‐zone approach based on imaging guided by clinical examination.
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Affiliation(s)
- A S Madsen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - W Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - M Smith
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - V Manchev
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Penetrating Neck Trauma: a Review. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0154-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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