Level II: CT angiography or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck. Bishara RA, Pasch AR, Douglas DD, et al. Of the 160 asymptomatic patients, 11 had injuries that did not require treatment. Decision to operate, or not, unclear. Gracias et al. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy, and esophagography in each patient before a mandatory exploration. Penetrating wounds of the neck. A twelve-year survey of cervicothoracic vascular injuries. Given the potential morbidity of missed injuries, clinicians should have a low threshold for obtaining imaging studies. Observation does not mandate extensive ancillary testing for level II and III injuries. Mandatory exploration is not necessary, but if nonoperative management is pursued, exploration may be needed if any change in clinical course occurs. Prospective evaluation of screening multislice helical computed tomorgraphic angiography in the initial evaluation of penetraing neck injuries. [47] in 160 patients. Weigelt et al. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Physical examination should be used to assess for possibility of injury in penetrating neck trauma. Some stable patients with evidence of upper aerodigestive tract injury can be managed without surgery, but a high index of suspicion for airway compromise and associated facial injuries must be considered. Accepted for publication December 18, 2007. Because there is often a need for urgent evaluation and treatment—bleeding and . Laryngotracheal trauma. Authors: Luis Fernando Barbosa Silva. Bostwick J III, Schneider WJ, Jurkiewicz MJ, et al. Early reports suggested that the physical examination is unreliable to rule out a vascular injury. They later[82] suggested that patients with bruits or thrills at admission may be better treated by undergoing conventional angiography because of the potential for endovascular therapy. [99] reviewed 109 patients with penetrating neck trauma. All rights reserved. Can J Surg. Concomitant esophageal injuries are frequent and predispose the patient to postoperative complications. Amazon Gives to EAST, EAST Guidelines & GRADE Resource Warehouse. Mandatory exploration is safe and appropriate. Selective management of penetrating neck trauma based on cervical level of injury. 1997;40 (1): 33-8. This study justifies selective rather than routine exploration. All zone II vascular injuries were symptomatic. In a study, by Stone and Callahan, vascular injuries in the neck accounted for 50% of deaths. [65] A negative arteriogram in a stable patient can rule out an arterial injury. Patients with minimal symptoms of visceral injury following penetrating cervical trauma may be selected for further evaluation based on the simple water swallowing test. [56], Management of neck wounds in the military setting may be different from that in the civilian world. Patients who underwent CT angiogram had fewer explorations (3% vs. 33%) and fewer negative explorations (0% vs. 32%). One blunt and 1 penetrating injury detected. [37]However, it has been shown that selective management can be safe in community hospitals with experienced surgeons. Vascular injury can be excluded by physical exam. 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. Massac E Jr, Siram SM, Leffall LD Jr. Penetrating neck wounds. Penetrating neck wounds. Esophageal gunshot injuries. In asymptomatic patients, Nason et al. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. There was no difference in hospital stay, morbidity, or mortality. Cheadle W, Richardson JD. Penetrating neck trauma: lack of universal reporting guidelines. 2007;65 (4): 691-705. Wounds treated during the first 6 h after injury should be closed primarily but with obligatory drainage. Goudy SL, Miller FB, Bumpous JM. Of 17 patients managed nonoperatively, only one developed local sepsis. Selective exploration for penetrating neck injuries is safe and cost-effective. Thomas AN, Goodman PC, Roon AJ. The problem with penetrating injuries to the esophagus is that there are frequently no findings on physical examination. [48] Hirshberg et al. Forty-two patients without any signs of injury were successfully observed without angiography or operation. Penetrating neck injuries: helical CT angiography for initial evaluation. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. Apffelstaedt and Muller[103] found that clinical signs were absent in 30% of patients with positive neck explorations and in 58% of patients with negative neck explorations, supporting their approach of mandatory exploration. This review supports the concept that therapy for penetrating injuries to the neck should be individualized. Management of penetrating neck injuries: a new paradigm for civilian trauma. Clinical evaluation preop not what is used for selective management. 65 patients underwent CT angiography. Penetrating injuries to the cervical oesophagus: is routine exploration mandatory? [74] studied 111 patients with penetrating neck trauma. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Gunshot wounds were more likely than stab wounds to cause vascular injury. Ngakane et al. If no significant injury is found, observation with repeated physical exams and 24 h availability of radiologic and endoscopic modalities must be adhered to. They suggested that proximity should not be abandoned as an indication for angiography in these patients. Debate on the issue of selective management continued as Meyer et al. Prompt operation, when appropriate, can spare patients unnecessary and costly testing. Mohammed GS, Pillay WR, Barker P, et al. Selective management of penetrating neck injuries based on clinical presentations is safe and practical. Prospective study of stable patients with gunshot wounds to the neck. Observation does not mandate extensive ancillary diagnostic testing for level II and III injuries. and hypovolemic shock, require In immediate surgical exploration. 91 patients underwent CT angio. The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The significance of these findings is difficult to determine, because they included all zones of the neck and did not define the severity of the injuries that were identified. Nonoperative management of penetrating neck wounds was common in the early 20th century. Methodology not consistent with current standards of care. Arteriography for penetrating neck trauma is usually unnecessary for observation of patients in stable condition without suggestive physical findings. Evidence suggests that selective operative management has equal results and outcomes. Zone II is the most exposed zone, and is consequently the most likely to be injured. Emergency tracheostomy should not be delayed if ventilation is compromised. Studies that examine penetrating trauma to all zones of the neck show consistently that zone 3 injuries are the least likely to occur and the most difficult to treat surgically. Nemzek WR, Hecht ST, Donald PJ, et al. Fifteen years' experience with penetrating trauma to the head and neck in children. 3. Godbole BG, Vira TM, Rao RV (1980) Stab injury of neck. All were observed without intervention. Based on a review of civilian experience, Fogelman and Stewart[5]recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. Campbell FC, Robbs JV. As the resolution of CT images improves, accuracy will surely increase. Physical examination, angiography, or color flow Doppler imaging. Selective management of penetrating neck trauma. Only one of these patients needed an operation. Level II recommendations, usually supported by Class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Zone 2 injuries are the most common, followed by Zone 1, and then Zone 3 1. Sriussadaporn et al. Helical CT angiography is limited by artifact due to metal which may obscure arterial segments; therefore, these patients should undergo conventional angiography. Ofer A, Nitecki SS, Braun J, et al. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the United States Department of Health and Human Services as follows: Class I-prospective, randomized, double-blinded study; Class II-prospective, randomized, nonblinded trial; or Class III-retrospective series, meta-analysis. Cost implications. Neither mandatory neck exploration nor mandatory arteriography is necessary. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. In the mandatory exploration group, the negative exploration rate was 53%. Arteriography and laryngoscopy/bronchoscopy were 100% accurate. Carefully selected patients can be observed for evolution of neck injuries with a resultant low morbidity and mortality. Selective management is safe and does not mandate diagnostic testing. Some studies specifically recommended that to manage penetrating neck injuries, a well-staffed teaching hospital with a trauma service and immediate availability of radiologic and endoscopic evaluations is needed. Physical examination is reliable in detecting significant injuries in penetrating neck trauma. Use of a double strand of absorbable Dexon to ligate the distal esophagus makes a second thoracotomy unnecessary for ligature removal. Selective management, when guided by repeated, careful examinations, is safe and avoids unnecessary operations. The neck has traditionally been divided into 3 anatomic zones 2. Ramadan HH, Samara MA, Hamdan US, et al. Though the sample size is small, there does appear to be an increased morbidity associated with the diagnostic workup and its inherent delay in operative repair of these injuries. Twenty-one percent had dysphagia, and 63% had stridor or hoarseness. There was one missed injury by CT angiography because the study actually did not include the entire neck. Minard G, Kudsk KA, Croce MA, et al. War injuries to the head and neck. Rapid definitive imaging studies may allow early discharge of patients with neck injuries. Overall, only one patient had a significant injury that was not predicted by physical examination. Acute penetrating arterial injuries of the neck and limbs. The role of clinical examination in excluding vascular injury in haemodynamically stable patients with gunshot wounds to the neck. Selective management of penetrating neck injuries. Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel. Inaba et al. Roon & Christensen`s Classification Zone 1: superiorly from the sternal notch & clavicles to the cricoid cartilage (injury affects both neck & mediastinal structures) Zone 2: cricoid cartilage to the angle of the mandible Zone 3: angle of the mandible to the 12. Level I: Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Retrospective study. Penetrating neck trauma: sensitivity of clinical examination and cost-effectiveness of angiography. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. CT was better than physical examination for identifying venous injuries, but most of these did not require intervention. This experience and a review of the literature support the concept of selective management of penetrating neck injuries with active observation. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. [70] found that esophagograms were 90% accurate and esophagoscopy was 86% accurate. Hirshberg A, Wall MJ, Johnston RH Jr, et al. Location and physical examination can rule out a major arterial injury necessitating operation. This was followed by zone I (40 patients, 18%) and zone III (43 patients, 19%). Apffelstaedt JP, Muller R. Results of mandatory exploration for penetrating neck trauma. Jarvik JG, Philips GR III, Schwab CW, et al. Grewal H, Rao PM, Mukerji S, et al. Regardless of method of management, those with a possibility of esophageal injury should undergo esophagram and/or esophagoscopy. Fogelman M, Stewart R. Penetrating wounds of the neck. Vascular injuries in zone II predominate over the other injuries located in zones I/III of the neck. Irish JC, Hekkenberg R, Gullane PJ et-al. Reinstitution of cerebral flow to a previously acutely ischemic brain adds greater risk of intracerebral hemorrhage. [80] reported that duplex US picked up two intimal flaps that were not identified on angiography. Patients were unlikely to have clinically significant vascular trauma if the above signs were missing. In stable patients, angiography helps avoid unnecessary operations and helped plan appropriate operations. Preoperative ancillary diagnostic tests would have further reduced the negative exploration rate. Clinical findings are a reliable indicator of significant trauma. Sixty patients underwent exploration for positive physical examination findings or a positive workup, whereas 269 asymptomatic patients were observed. Selective management is safe. Those patients without immediately life-threatening injuries, but with any signs of vascular complication, signs of upper aerodigestive tract lesions, or peripheral neurological deficits, should undergo thorough imaging to determine the need for and nature of possible surgical intervention. In a series of 128 asymptomatic patients who were observed by Biffl et al.,[41]based primarily on physical examination, only one patient had a missed injury (from an ice pick). Nonoperative observation of penetrating zone-II neck injuries is safe and the management of choice if active observation can be performed and the facilities for immediate operative intervention are available. [112] Forty-two patients, who did not have obvious need for operation at admission, underwent soft tissue dynamic CT of the neck and esophagography before mandatory exploration. Laryngotracheal trauma usually presents with symptoms and/or signs, but they may be minimal and nonspecific. Both sensitivity and negative predictive value for injuries requiring operation were 100%. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds. Selective exploration of penetrating neck wounds is both safe and reasonable. ISRN Emergency Medicine, vol. To examine the cost effectiveness of angiography, Jarvik et al. Hartling RP, McGahan JP, Lindfors KK, et al. Demetriades D, Theodorou D, Cornwell E, et al. Selective management of neck injuries should be done. June 2019; DOI: 10.20873/uft.2446-6492.2019v6n2p38. Zones of the Neck and Anatomical Structures. The Montgomery T-tube used in our second J Postgrad Med 26:257–258. Gunshot wounds cause vascular injury more frequently than stab wounds. [111] reviewed the cases of 19 patients with emphysema or crepitance. At that time, standard management included either AG or surgi-cal exploration, these being considered the only acceptable methods of evaluating such wounds for vascular injury. American University of Beirut Medical Center. Hersman G, Barker P, Bowley DM, et al. They recommended mandatory exploration. Penetrating visceral injuries of the neck: results of a conservative management policy. Selective management based on physical examination is appropriate. Roden DM, Pomerantz RA. [68] found, using angiography, that 43 patients with stab wounds to the neck and minimal symptoms had no significant injuries. Vascular injury incidence was 30% when there was an absent pulse, bruit, hematoma or alteration of neurologic status. In the setting of a mandatory exploration protocol, Mazolewski et al. Biffl WL, Moore EE, Rehse DH, et al. No major arterial injuries that were missed preoperatively were discovered during exploration. Narrod JA, Moore EE. Penetrating injuries of the neck: selective management evolving. In addition, some of the clinically silent injuries were venous and pharyngoesophageal injuries, which did not require operative therapy. Treatment of neck injury depends on the severity of injury and the zones of the neck which are involved. Penetrating wounds of the neck and upper thorax. Prgomet et al. Therefore, selective management is recommended to minimize unnecessary operations. Hiatt JR, Busuttil RW, Wilson SE. For centers practicing selective management, rapid diagnosis and definitive repair should be made a high priority. Color Doppler sonography in penetrating injuries of the neck. [38] Evidence of chest injury does not seem to be an indication for neck exploration.[39]. [9][10], Mandatory exploration gained in popularity as studies showed that clinical symptoms were not present in 0% to 23% of the cases. [94] also found that patients with small injuries and contained perforation on contrast studies could be observed without operation unless there was another indication for exploration. | read full message, EAST - The Eastern Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Injury Control and Violence Prevention Resources, Interviews with Research Scholarship & Award Recipients, Amazon Smile: You Shop. Klyachkin ML, Rohmiller M, Charash WE, et al. Munera F, Soto JA, Nunez D. Penetrating injuries of the neck and the increasing role of CTA. All 91 other patients with negative physical examinations were safely observed without imaging. Most prospective studies suggest that STABLE patients with TS-GSW’s can have a selective surgical approach 6) Describe the management of suspected pharyngoesophageal trauma. A severe pain response on swallowing should elicit a contrast swallow. [radiopaedia.org] Other possible treatments include neck braces, medications and injections, and surgery. Vascular injury is the most common complication of penetrating neck trauma, occurring in 25%, with mortality of nearly 50%. Shama DM, Odell J. Penetrating neck trauma with tracheal and oesophageal injuries. Routine versus selective exploration of penetrating neck injuries: a randomized prospective study. Noyes et al. [71] found that 10 of 26 patients who had positive angiograms for penetrating vascular injury to the neck had undergone the angiogram solely because of proximity. Corr et al. Published 2008 Risk of significant injury to vital structures in the neck is dependent on the penetrating object. Transcervical gunshot injuries: mandatory operation is not necessary. The data support the application of the selective management algorithm for zone II neck wounds. Helical CT angiography can be reliably used to evaluate penetrating neck trauma in the stable patient. The best study, though small, that attempted to determine whether imaging adds to physical examination in the evaluation of patients with penetrating neck injuries was that by Gonzalez et al. Lundy LJ Jr, Mandal AK, Lou MA, et al. Most underwent direct laryngoscopy and esophagoscopy. Selective management of gunshot wounds to the neck. Montalvo BM, LeBlang SD, Nunez DB Jr, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. 10 patients without signs of vascular injury had a vascular injury, but the nature of these injuries was not described. Physical examination is insufficient. Non-diagnostic studies were secondary to retained missile fragments. Shuck JM, Gregory J, Edwards WS. Stab wounds to the neck: role of angiography. Menawat et al. No conclusions can be drawn from their data. The sensitivity and specificity of helical CT angiography are high for detection of major carotid and vertebral arterial injuries resulting from penetrating trauma. Velmahos GC, Souter I, Degiannis E, et al. J Vascular Surgery. Ordog GJ, Albin D, Wasserberger J, et al. Transcervical injuries are more lethal than other types of injuries to the neck. Level I recommendations, usually based on Class I data, were meant to be convincingly justifiable on scientific evidence alone. When the general condition of the patient permits, barium swallow is extremely reliable method for demonstrating esophageal perforation.