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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 l.jpg

Penetrating Neck Injuries:Mandatory Exploration vs. Nonoperative Management

Bradley J. Phillips, MD

Burn-Trauma-ICU

Adults & Pediatrics


Debate continues l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg

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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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


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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


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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%


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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 l.jpg
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


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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 l.jpg

“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 l.jpg
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 l.jpg
    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 l.jpg
    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 l.jpg
    Penetrating Neck Trauma - Radiographic Options

    • Arteriography

      • “gold standard”

      • no or minimal complications

    • Controversial

      • Duplex scan

      • CT angiogram


    Angiography l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    Treatment - Esophageal Injury

    • Negative studies/high suspicion

      • 24 hr observation

    • Pharyngeal

      • usually non-operative

      • NPO/IV Abx

    • Esophageal

      • resection

      • ? diversion


    Primary vs exclusion diversion l.jpg
    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 l.jpg
    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 l.jpg
    Esophageal Injuries

    • Additional considerations

      • Antibiotics (cover oral flora)

      • NGT (5-7 days)

      • GT and JT placement

      • ? Thoracic duct injury


    Penetrating laryngotracheal trauma l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    Keys to Diagnosis & Management

    • High index of suspicion

    • Airway management !

    • Sense of urgency

    • Operation vs radiology


    Overview management penetrating neck l.jpg
    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