'No zone' approach in the management of penetrating neck injuries - an Australian Tertiary Trauma Centre experience

PURPOSE

Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone-based approach to a 'no zone' algorithm, resulting in reduced non-therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a 'no zone' approach could be safely implemented in this population, as has been demonstrated internationally.

METHODOLOGY

This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT-A) use and operative intervention. Patients were examined based on zone of injury and presenting signs - 'hard', 'soft' or 'asymptomatic'. Major outcomes were CT-A usage, positive CT-A correlation with therapeutic neck explorations and negative neck exploration rates.

RESULTS

This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT-A utilization increased from 55% to 94.1%, with positive CT-As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non-therapeutic neck explorations.

CONCLUSION

Our data suggests similarities with results from around the world, demonstrating that the 'no zone' approach should be considered when managing PNIs, but with clinician discretion in individual cases.

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.

Blunt and Penetrating Airway Trauma

Airway injury, be that penetrating or blunt, is a high-stakes high-stress management challenge for any airway manager and their team. Penetrating and blunt airway injury vary in injury patterns requiring prepracticed skills and protocols coordinating care between specialties. Variables including patient cooperation, coexisting injuries, cardiorespiratory stability, care location (remote vs tertiary care center), and anticipated course of airway injury (eg, oxygenating well and comfortable vs increasing subcutaneous emphysema) all play a role in determining airway if and when airway management is required. Direct airway trauma is relatively infrequent, but its presence should be accompanied by in-person or virtual otolaryngology support.

Airway Management for Penetrating Neck Trauma: A Case Report

Penetrating neck injuries comprise 5-10% of traumatic injuries in adults and can cause immediate life-threatening compromise. Performing awake fibreoptic intubation in cooperative patients when airway management is not time critical has been suggested as a method of securing these potentially complicated airways. We report a case of a male in his 20s who presented to the emergency service with neck trauma following a bicycle road accident. With the exception of a wound in the neck region, there were no alarming distress signs or symptoms of airway endangerment. Imagiological evaluation revealed a rupture of the right lateral tracheal wall. He was referred for urgent surgery. We performed intubation with video laryngoscopy assisted by a neck surgery team, keeping the patient breathing spontaneously and under deep sedation. After advancing the tube through the vocal cords, the surgeon explored the cervical wound, guiding the tube through the trachea. Keeping spontaneous ventilation and advancing the tracheal tube beyond the lesion under visualization is essential when managing a traumatized airway. Tracheal intubation using video laryngoscopy, assisted by a neck surgeon guiding the tube, and avoiding creation of a false passage can be a safe alternative to fibreoptic intubation in selected cases of tracheal laceration.

"Penetrating Neck Injuries: A Comprehensive Study"

Penetrating neck injuries are defined as injury to the neck associated with breach in the platysmal muscle layer. All penetrating neck injuries are potentially dangerous and require emergency intervention due to its proximity to airway, important blood vessels, nerves and other organs in the neck. A complete evaluation, rapid airway intervention and proper surgical repair are highly essential to prevent complications. Clinical evaluation and management of penetrating neck injuries at a tertiary care hospital. In this study, 66 cases of penetrating neck injuries who presented to the emergency department from October 2018 to September 2020 were included. The particulars of the insult like type of instrument causing injury and zone of injury were compared. An analysis of the management of penetrating neck injury with respect to exploration and wound repair and the need for tracheostomy, vascular repair, esophageal repair, laryngeal framework repair and pharyngeal repair was made. The maximum incidence was observed for the age group between 21 and 30 years. The object causing the maximum number of neck injuries was knife, in 36 cases. The distribution of cases according to zone of injury revealed that the zone II was most commonly affected in 43 cases. The structures injured in the study indicated that platysma was involved in all the cases, followed by thyroid cartilage in 33 cases. Wound exploration and repair was done in all cases and tracheostomy was done in 44 cases. Complications were vocal cord palsy in 19 patients, 15 had tracheal stenosis, 13 had hoarseness of voice, 7 developed pharyngocutaneous fistula and 1 developed pharyngeal stenosis. There were 2 deaths. 16 patients who attempted suicide had depression. All penetrating neck injuries are potentially dangerous and require emergency treatment because of the presence of important vessels, nerves andorgans in the neck. Thorough knowledge of the anatomy of neck, clinical assessment and diagnostic and therapeutic interventions are necessary for appropriate management.

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.

The Management of Penetrating Neck Injury With Retained Knife: 15-Year Experience From a Major Trauma Center in South Africa

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.

Chronic respiratory dysfunction due to diaphragmatic paralysis following penetrating neck trauma: A case report

RATIONALE

Respiratory dysfunction resulting from unilateral diaphragmatic paralysis during neck trauma is very rare in adults. We describe the symptoms, diagnosis and treatment of 1 patient with chronic respiratory insufficiency, in whom the diaphragmatic paralysis was associated with phrenic nerve injury due to penetrating neck trauma.

PATIENT CONCERNS

A 50-year-old worker was admitted because of left penetrating neck trauma. Imaging investigations demonstrated elevation of the left hemidiaphragm and the C5 and C6 roots avulsion. He complained of gradually worsening dyspnea on exertion 2 months later.

DIAGNOSES

The patient was diagnosed with chronic respiratory dysfunction secondary to diaphragmatic paralysis, which caused by phrenic nerve injury.

INTERVENTIONS

A conventional video-assisted thoracoscopic diaphragm plication was performed after failed conservative management.

OUTCOMES

The respiratory status improved markedly, and he did well without recurrence until 2 years' follow-up.

LESSONS

The possibilities of phrenic nerve palsy and diaphragmatic paralysis should not be overlooked during the evaluation of neck trauma.

'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.