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Penetrating Neck Injuries: Mandatory Exploration vs. Nonoperative Management. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Debate Continues……….

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penetrating neck injuries mandatory exploration vs nonoperative management

Penetrating Neck Injuries:Mandatory Exploration vs. Nonoperative Management

Bradley J. Phillips, MD

Burn-Trauma-ICU

Adults & Pediatrics

debate continues
Debate Continues………

“ Some authors have advocated mandatory exploration of all penetrating neck wounds on the basis that serious injury can exist in the absence of clinical findings. Others have advocated a selective approach, operating only upon patients whose finds suggest a major vascular or visceral injury.”

A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979, 19:391

overview penetrating neck injuries
Overview – Penetrating Neck Injuries
  • Management based on “Neck Zones”
    • Background
    • Rationale for and against
  • General clinical diagnosis
  • Specific injuries – Diagnosis and Management
    • Carotid
      • Zone II – Mandatory Exploration vs. Selective Nonoperative
    • Vertebral
    • Esophagus
    • Larynx
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 1979
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Retrospective study
    • 189 patients from 1970 -1977
    • GSW = 49, SW = 140
  • Treatment options
    • Based on location of neck wound
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 19797
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Neck zones
    • Considered level of entrance wound important part of preoperative evaluation
    • Based on involved vascular structures where distal or proximal control viewed as difficult
    • Obtained arteriography on all patients with high or low neck wounds
      • Vascular injury may not obvious
      • Plan appropriate operative approach to minimize bleeding
penetrating neck zones

Zone III

Zone II

Zone I

Penetrating Neck Zones

A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979, 19:391

a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 19799
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Clinical findings
    • 74 % had one or more signs of vascular, UGI or airway injury
      • hemorrhage (50%)
      • hematoma (34%)
      • shock (15%)
      • neurologic signs (12%)
    • 26 % no signs (only 6 % had positive explorations)
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 197910
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Location of wounds
    • Middle zone (98 pts)
    • Low or high zone (91 pts)
  • Treatments
    • Middle zone – immediate exploration
    • Low or high zone – angiogram if stable (62 pts)
      • negative = 47
      • positive = 14
      • false positive = 1
      • false negative = 0
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 197911
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Results
    • 35 patients not explored
    • 154 patients explored
      • 47% positive findings
        • GSW 59%
        • SW 43%
    • 123 repairs performed
      • Venous – 46
      • Arterial – 36
      • Airway – 26
      • Esophageal – 3
      • Miscellaneous - 11
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 197912
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Mortality (2.6 %)
    • Positive explorations = 2.6 %
    • Observation = 0%
    • Negative exploration = 0%
  • Morbidity (5.3%)
    • Observation = 0 %
    • Negative exploration = 4 %
    • Positive exploration = 7 %
a j roon and n christensen evaluation and treatment of penetrating cervical injuries j trauma 197913
A.J. Roon and N. Christensen, Evaluation and Treatment of Penetrating Cervical Injuries, J Trauma, 1979
  • Conclusions
    • All patients with wounds penetrating the platysma should have a neck exploration
    • Patients with high or low wounds should have preoperative arteriograms if they are stable
      • Time to exploration
        • no arteriogram = 2.4 hrs
        • arteriogram = 4.8 hrs
      • Angiogram changed approach ( 6 %)
    • Repair all vascular injuries, unless carotid occluded
    • Lower mortality with mandatory exploration (?)
      • Observation = 0 % (required more radiological studies, time, effort, cost)
      • 2.6 % compared to reported 10-30% with selective observation
neck zone concept outdated
Neck Zone Concept Outdated ?
  • Location of skin wound not a reliable indictor of underlying injuries
  • Length of neck makes it impractical to divide into three short zones
  • Wounds often occur at border between zones and difficult to classify
epidemiology of penetrating neck injuries
Epidemiology of Penetrating Neck Injuries
  • 40% do not involve important structures
  • Types
    • GSW 50% (direct and indirect damage)
    • SW 45%
    • Shotgun 5%
  • Structures involved
    • major vein 15-25%
    • major artery 10-15%
    • pharynx or esophagus 5-15%
    • larynx or trachea 4-12%
    • major nerves 3-8%
stab vs gunshot wounds
Stab vs. Gunshot Wounds
  • Anecdotal suggestion
    • explore GSW, non-operative SW
    • not supported in literature
  • Prospective study (Demetriades et al, Br J Surg, 1993)
    • 97 GSW, 89 SW
    • GSW higher incidence of clinical signs than knives (35% vs. 19%)
    • GSW more likely injuries
    • therapeutic operation: GSW 16.5%, SW 10.1%
clinical diagnosis neck injuries
Clinical Diagnosis – Neck Injuries
  • Significant injuries often asymptomatic
    • 25% positive symptoms and 25% positive signs
    • PE is often deceptively negative for severe injury
  • Symptoms variable and delayed
    • internal carotid artery > 2 weeks
    • esophageal
      • Weigelt et al, Am J Surg, 1987; 154:619
        • 3/10 no signs or symptoms
    • laryngeal
      • more likely to have presenting symptoms/signs
      • voice change, SOB, hemoptysis
case 1
Case #1
  • 21 yom with GSW to right neck without exit site
  • c/o pain in throat/right neck
  • VS : HR 110, BP 130/70, RR 27 sats 98% (40%)
  • PE:
    • mild swelling right neck, non-pulsetile
  • Management options ?
  • observation (physical exam based)
  • selective approach
  • diagnostic approach
  • mandatory exploration
clinical signs vascular injury
“Hard”

Active or pulsetile bleeding

Expanding hematoma

Bruit or thrill

Neurologic deficit (unilateral)

Deficit pulse exam

Hypotension

“Soft”

Nonexpanding hematoma

Paresthesias

Clinical Signs – Vascular Injury
physical exam missed injuries
Physical Exam – Missed Injuries
  • Fogelman MJ and Stewart RD , Am J Surg,1956, 91:581
      • 100 consecutive patients
      • 43% hemodynamically stable
      • 70% no sign of bleeding
  • Carducci et al, Ann Emerg Med, 1985, 15:208
      • 1/3 of patients without signs/symptoms
  • Apffelstaedt et al, World J Surg, 1994, 18:917
      • Prospective study, 335 patients
      • SW penetrating platysma
      • clinical signs absent 30% of positive neck explorations
physical exam reliable diagnosis
Physical Exam - Reliable Diagnosis
  • Demetriades et al, Br J Surg, 1993
    • Prospective, 335 patients, detailed written protocol
    • 7/335 required angiography
    • 269/335 non - operatively managed
      • 2 required subsequent operations for vascular injury
      • no complications
  • Demetriades et al, World J Surg, 1996, 21:41
    • Prospective, 223 patients, strict written protocol
    • 160/223 - no clinical signs underwent angiogram
      • no vascular injury requiring treatment (NPV 100%)
physical exam reliable diagnosis22
Physical Exam – Reliable Diagnosis
  • Biffl et al, Am J Surg, 1997, 174:678
    • Prospective, 312 patients with penetrating neck injuries
      • Immediate OR = 105 (symptomatic)
        • 16 % non-therapeutic
      • Observation only = 207 (asymptomatic)
        • 1 delayed operation for esophageal perforation
  • Sekharan et al, J Vasc Surg, 2000, 32:483
    • Prospective, 145 Zone II injuries
      • Immediate OR = 31 patients (hard signs)
        • 90% with major arterial/venous injury requiring repair
      • Observation = 91 patients
      • Arteriography = 23 patients
        • 1 required operative repair of common carotid artery
penetrating neck trauma radiographic options
Penetrating Neck Trauma - Radiographic Options
  • Arteriography
    • “gold standard”
    • no or minimal complications
  • Controversial
    • Duplex scan
    • CT angiogram
angiography
Angiography
  • Recommended in Zone I and III
    • difficult to assess clinically
    • difficulty surgical exploration
  • Policy reduces non-therapeutic intervention
  • Costs (Demetriades et al, Br J Surg, 1993)
    • Zone I only 5% required operation
    • Zone III only 13% required operation
zone i injuries angiography
Zone I Injuries - Angiography
  • Eddy, et al, J Trauma, 2000, 48:208
  • ? Mandatory angiography in all Zone I injuries
  • Retrospective over 10 years, 138 patients
  • Arteriography vs. Physical exam/CXR
  • Results
    • 28 arterial injuries identified
    • 36 patients had normal PE and CXR
    • No arterial injuries identified in PE/CXR group
penetrating neck injuries duplex
Penetrating Neck Injuries - Duplex
  • Demetriades et al, Arch Surg, 1995, 130:971
    • Prospective, 82 stable patients with neck wounds
    • Angiography and color flow doppler imaging
    • Zones: I - 30%, II - 53%, III - 31%
    • Angiography
      • Identified 11 lesions, 2 required repair
    • Doppler
      • Identified 10 lesions, missed intimal tear in CCA
      • 91% sensitive, 99 % specific
      • 100% for clinically important lesions
penetrating neck injuries duplex28
Penetrating Neck Injuries - Duplex
  • Ginzberg et al, Arch Surg, 1996, 131:691
    • Prospective, 55 stable penetrating neck wounds
    • Duplex ultrasonography in all patients
    • Compared results with arteriography or OR findings
    • Results
      • Duplex
        • Normal - 76%
        • Abnormal – 24% ( 11 truly abnormal, 2 false positive)
    • Outcomes
      • NPV 100%
      • PPV 85%
penetrating neck injuries ct angiogram
Penetrating Neck Injuries – CT Angiogram
  • Gracias et al, Arch Surg, 2001, 136:1231
    • Retrospective, 23 stable patients with neck injuries
    • Helical CT angiogram for trajectory determination
    • Results
      • 13/23 had trajectories remote to vital structures
        • No further intervention
    • 10/23 underwent angiogram (3 required embolization)
  • Outcomes
    • No adverse outcome
    • Prolonged time to angiogram via CT (added 1.5 hrs)
    • 4 discharge from ED
zone ii injuries ct angiogram
Zone II Injuries – CT Angiogram
  • Mazolewski et al, J Trauma, 2001, 136:1231
    • Prospective, 14 stable Zone II injuries
    • Helical CT angiogram then exploration
    • Surgeons predicted 4/14 significant injuries by CT scan
    • Results
      • 3/14 patients with significant injuries
      • Correlated with CT findings
    • Outcomes
      • Sensitivity 100%, NPV 100%
management mandatory exploration
Management - Mandatory Exploration
  • Mandatory exploration
    • Advantages
      • decreased injuries
        • up to 25% unexpected injuries found
      • low morbidity/mortality
    • Disadvantages
      • report up 67% negative exploration
    • Recommendations
      • Zone II injuries with/without instability
      • GSW that cross midline
supportive mandatory exploration
Supportive – Mandatory Exploration
  • Meyer et al, Arch Surg, 1987, 122:592
    • Prospectively studies 120 Zone II injuries
      • Emergent OR = 7
      • Diagnostic evaluation followed by neck exploration = 113
        • Arteriography
        • Barium swallow and flexible esophagoscopy
        • Laryngoscopy
    • Outcome accuracy
      • Clinical assessment = 86 %
      • Diagnostic assessment = 94 %
      • Operative assessment = 100 %
    • Complications = 6%, Mortality = 0.8%
management selective approach
Management - Selective Approach
  • If hemodynamically stable
    • angiography, contrast study, endoscopy , laryngoscopy
  • Exploration if positive study
  • Negative neck exploration 20%
  • Disadvantages
    • cost and time
    • iatrogenic (CVA, esophageal perforations)
supportive selective approach
Supportive – Selective Approach
  • Jurkovich et al, Trauma, 1985, 25:819
    • Missed injuries negligible
  • Sofianos et al, Surgery, 1996, 120:785
    • Prospectively studied 75 Zone II injuries
      • Immediate operation = 40 (hard signs present)
      • Selective approach = 35
        • Only 11 had either arteriography, contrast swallow, or endoscopy
    • No incidence of missed injury, morbidity, or mortality
transcervical gsw
Transcervical GSW
  • More likely to involve vital structures
    • 73% vs. 31% (GSW not cross midline)
  • Hirshberg et al, Am J Surg 1994
    • retrospective 41 patients
    • 30(83%) positive for cervical injury
    • recommends mandatory exploration
  • Demetriades et al, J of Trauma, 1997
    • prospective, 33 patients
    • 73% injury to vital organ, only 21% therapeutic operation
treatment options carotid artery injuries
Treatment Options – Carotid Artery Injuries
  • Carotid injuries
    • 22% of penetrating cervical vascular injuries
    • mortality 10-20% (in-hospital)
    • Repair vs. ligation
      • repair if possible in absence of neurologic deficits
      • prefer saphenous vein, but prosthetics ok
      • if internal carotid injuries, transposition of external carotid
      • ligation in neurologically intact for high internal carotid injury if very difficult or impossible
treatment options neurologic deficits
Treatment Options – Neurologic Deficits
  • Presence of neurologic deficits
    • controversial
    • ? concern of post-vascularization hemorrhagic infarct
    • increased risk if evidence of severe anemic infarct or edema
    • recommend repair
      • if deficits are short of coma
      • no evidence of anemic infarct
      • patent distal carotid
treatment intimal flaps
Treatment – Intimal Flaps
  • Minor carotid injuries (intimal flaps)
    • natural history not known
    • controversial: observation vs. aggressive approach
    • ? role of duplex for decision making
    • role of anti-platelet unproven, but used
management vertebral artery injuries
Management – Vertebral Artery Injuries
  • Vertebral artery
    • increased frequency secondary liberal angiography
    • 10% of major vascular injuries
    • 67% have association with major cervical injury mainly spine
    • isolate injury asymptomatic in 1/3 patients
    • thrombosis rarely lead to neurologic sequelae
    • angiographic embolization standard of care if bleeding
complications vertebral artery injuries
Complications – Vertebral Artery Injuries
  • Nonoperative Management
    • delayed bleeding
    • CVA (dissection, emboli)
    • pseudoaneurysm
    • sepsis (missed esophageal leak)
  • Operative Management
    • injury to nerves (vagus, hypoglossal, recurrent)
    • blood loss
    • missed injury (particularly esophageal)
summary treatment vascular injury
Summary Treatment - Vascular Injury
  • Surgical exploration unstable and stable Zone II (board answer)
  • Angiography Zone I and III
  • ? Nonoperative management stable Zone II
    • depends on expertise and facilities
  • Other interventions
    • embolization high carotid or vertebral artery
    • endovascular stent (pseudoaneurysms)
    • anticoagulation blunt carotid/vertebral artery
diagnosis esophageal injuries
Diagnosis – Esophageal Injuries
  • Blunt esophageal injury rare
  • High index of suspicion in blunt trauma
  • Penetrating trauma
    • evaluation part of a complete work-up
  • If missed, high morbidity/mortality
esophageal injury diagnostic test
Esophageal Injury - Diagnostic Test
  • Contrast swallow
    • Extravasation is diagnostic
    • Negative study is not reliable (particular in neck with gastrograffin)
    • 50% of leaks missed with gastrograffin
    • 25% of leaks missed with barium
esophageal injury diagnostic tests
Esophageal Injury - Diagnostic Tests
  • Controversy of initial contrast to use
    • gastrograffin
      • pneumonitis if aspirated
    • barium
      • increased inflammation/infection in the mediastium
  • Recommendation: If gastrograffin study is negative, repeat swallow this barium. Avoid gastrograffin in patients without gag/cough or unprotected airway
esophageal injury diagnostic test53
Esophageal Injury - Diagnostic Test
  • Endoscopy
    • Generally recommended when contrast swallow is negative, but suspicion is high
    • Perforations often readily seen, however
      • 50% missed (Weigelt et al Am J Surg 1987)
      • missed in pharynx and cervical esophagus
      • missed in patients on ventilator (poor expansion of esophagus)
  • Combination of swallow/esophagoscopy reduces missed injuries to < 5%
esophageal injury delay in diagnosis
Esophageal Injury - Delay in Diagnosis
  • AAST Multicenter Study – Penetrating Esophageal Injury
  • Arsensio, et al, J Trauma, 2001, 50:289
    • 34 US centers over 10 years
    • Retrospective 346 patients
    • Two groups: immediate OR vs. diagnostic testing
    • Results
      • Time to OR: preop evaluation -13 hrs., no preop - 1 hr.
      • Complications
        • Overall: preop – 134, no preop – 87 (p < 0.001)
        • Esophageal related: preop – 74, no preop – 32 (p< 0.003)
      • Overall Mortality – 19%,
    • Outcomes independent risk factors
      • Time delays in preop evaluation, OIS > 2, and resection/diversion
treatment esophageal injury
Treatment - Esophageal Injury
  • Negative studies/high suspicion
    • 24 hr observation
  • Pharyngeal
    • usually non-operative
    • NPO/IV Abx
  • Esophageal
    • resection
    • ? diversion
primary vs exclusion diversion
Primary vs. Exclusion-Diversion
  • Virtually all injuries can be repaired primarily
  • Management dictated
    • Site of injury
    • Associated injuries
    • Condition of patient
    • Timing of repair ( < or > 24 hrs.)
  • Surgical Options
    • Primary with reinforcement of flap/patch
    • Exclusion-diversion
exclusion diversion
Exclusion/Diversion
  • Usually > 24 hrs post injury
  • Sepsis and extensive inflammation
  • Primary goal – DRAINAGE
  • Approach based on injury location
    • Cervical
      • Small – often simple drainage
      • Large – spit fistula
    • Thoracic
      • Extensive debridement, drainage
      • Repair with a Grillo flap (pleura)
      • Exclusion/diversion +/- continuity (Urschel repair)
      • T-tube drainage (large defects or contamination
      • Esophagectomy (rare)
esophageal injuries
Esophageal Injuries
  • Additional considerations
    • Antibiotics (cover oral flora)
    • NGT (5-7 days)
    • GT and JT placement
    • ? Thoracic duct injury
penetrating laryngotracheal trauma
Penetrating Laryngotracheal Trauma
  • 5-15% of penetrating neck trauma
    • larynx 33%
    • cervical trachea 67%
  • Doubled if esophagus injury
  • 25% of airway injuries have esophageal injury
diagnosis laryngotracheal injury
Diagnosis - Laryngotracheal Injury
  • Pathology
    • subglottic/supraglottic submucosa edema/air
    • usually occurs within 6 hours
    • > 70% cross-sectional area reduced before symptoms
  • Associated with cervical spine injury
  • Voice change most common
  • Other S/S: dyspnea, pain, score throat, dysphagia, odynophagia, hemoptysis, subcutaneous air
diagnosis laryngotracheal injury61
Diagnosis - Laryngotracheal Injury
  • Plain xrays
    • soft tissue emphysema
    • airway compression
    • fracture of laryngeal cartilages
  • CT scan
    • detailed and accurate appraisal
  • Endoscopy
    • Flexible vs rigid
    • Bronchoscopy/laryngoscopy 100% accurate
management of laryngotracheal injury
Management of Laryngotracheal Injury
  • Airway control
  • Preparation for surgical airway
  • Non-operatively if,
    • clinically stable airway
    • endoscopy shows no displaced cartilages, mucosal disruptions or progressive edema/hematoma
    • therapy
      • semi-fowler position, humidified air, steroids, IV abx
management of laryngotracheal injury63
Management of Laryngotracheal Injury
  • Operative
    • tracheostomy if airway unstable
    • no advantage in delay > 24 hrs to repair fx
    • laryngeal fractures
      • thyroid fx most common
      • reduction and fixation with stainless +steel sutures
      • delay of reduction > 7-10, scarring makes it more difficult and return of normal function unlikely
outcomes of laryngotracheal injury
Outcomes of Laryngotracheal Injury
  • 1/3 of patients who survive airway injury reach hospital alive suffer delay in diagnosis and treatment
  • preventable death in 10% in upper airway trauma (most secondary to delay)
  • most have some permanent voice and airway impairment or tendency to aspirate
  • problems most significant after blunt injury and penetrating (more extensive damage)
errors in management of laryngeal trauma
Errors in Management of Laryngeal Trauma
  • Assuming airway problem in unconscious patient is only due to prolapse of the tongue
  • Attempting blind intubation in suspected larygneal injury
  • Inserting ET tube with force is through vocal cords and fails to advance
  • Use of muscle relaxation in a patient with a possible cricotracheal separation
  • Inadequate assessment of esophageal injury
mortality morbidity of neck injuries
Mortality/Morbidity of Neck Injuries
  • Mortality
    • Vietnam era – 4-7 %
    • Today - 2-6 %
    • Higher if
      • missed cervical injuries - > 15 %
      • Loss of airway patency – 33 %
  • Morbidity
    • Respiratory compromise 10 %
  • Zone I injuries highest mortality/morbidity
keys to diagnosis management
Keys to Diagnosis & Management
  • High index of suspicion
  • Airway management !
  • Sense of urgency
  • Operation vs radiology
overview management penetrating neck
Overview - Management Penetrating Neck
  • Zone I
    • Routine angiography vs. CT angiogram
    • Esophageal evaluation (contrast swallow +/- EGD)
    • Airway evaluation (laryngoscopy or bronchoscopy)
  • Zone II
    • Diagnostic vs. selective approach
    • Mandatory exploration fading
  • Zone III
    • Routine angiography vs. CT angiogram
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