An audit of penetrating neck injuries in a South African trauma service

doi:10.1016/j.injury.2015.07.032

Injury

Volume 47, Issue 1, January 2016, Pages 64-69

https://doi.org/10.1016/j.injury.2015.07.032 Get rights and content

Abstract

Introduction

This study reviews and validates the practice of selective non-operative management (SNOM) of penetrating neck injury (PNI) in a South African trauma service and reviews the impact new imaging modalities have had on the management of this injury.

Methodology

This study was performed within the Pietermaritzburg Metropolitan Trauma Service, in the city of Pietermaritzburg, Kwazulu-Natal, South Africa. A prospectively maintained trauma registry was retrospectively interrogated. All patients with PNI treated over a 46-month period were included within the study.

Results

A total of 510 patients were included in the study. There were 452 stab wounds (SW) and 58 gunshot wounds (GSW). A total of 202 (40%) patients sustained isolated PNI, the remaining 308 (60%) patients sustained trauma to at least one additional anatomical region. An airway injury was identified in 29 (6%) patients; a pharyngo-oesophageal injury in 41 (8%) patients and a vascular injury in 86 (17%) patients. Associated injuries included three penetrating cardiac injuries (PCI) and 146 patients with haemo-pneumothoraces. Of the total cohort, 387 patients (76%) underwent CT Angiography (CTA), of which 70 (18%) demonstrated a vascular injury. Formal catheter directed angiogram (CDA) was performed on 16 patients with positive CTA but confirmed injury in only half of these patients. Of 212 patients (42%) who underwent water-soluble contrast swallow (WS-swallow), an injury was demonstrated in 29 (14%) cases. A total of 401 (79%) patients were successfully managed conservatively for PNI and 109 (21%) surgically or by endovascular intervention. Only five (1.2%) patients failed a trial of SNOM and required surgery. The in-hospital mortality rate was 2%. No deaths could be attributed to a failure of SNOM.

Conclusion

SNOM of PNI is a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity, is associated with a low yield. CTA has a significant false positive rate and good clinical assessment remains the cornerstone of management.

Introduction

Mandatory neck exploration for penetrating neck injuries (PNI), leads to a high rate of negative exploration and selective non-operative management (SNOM) of PNI has long been established as a management philosophy in South Africa [1], [2], [3], [4], [5], [6], [7], [8], [9]. Most of the original work documenting the applicability of SNOM to PNI dates from the era prior to the advent of new imaging technologies such as CT angiography (CTA) and endovascular surgery. On-going audit is essential to help us contextualize these new modalities and to ensure that they are integrated positively into our existing management algorithms in a way that adds value rather than merely complicates clinical scenarios. There are also subsets of injuries particularly those of the aero-digestive tract, in which the optimal management strategies still remain controversial [10], [11], [17], [18], [19], [20]. This retrospective review of a prospectively maintained electronic registry and medical record system was undertaken to review the current spectrum and burden of the problem and to review the outcomes of our management strategy in light of the advent of newer technologies. It was also hoped that with the new powerful method of capturing clinical data we would be able to analyse the controversial subsets of injuries in more detail.

Section snippets

Methodology

The Pietermaritzburg Metropolitan Trauma Service (PMTS) maintains a prospective digital trauma registry, which captures data at our institutions. Ethics approval to maintain the registry has been obtained from the Biomedical Research Ethics Committee (BCA221/13 BREC) of the University of KwaZulu-Natal and from the Research Unit of the Department of Health [12]. Patients with PNI treated from January 2011 to November 2014 were included in the study and data pertaining to the following criteria

Management of PNI

All neck wounds are classified as either posterior to the posterior border of the sternocleidomastoid muscle, or anterior to the posterior border of the muscle [2], [3]. Anterior wounds are sub-classified according to zone as described by Roon and Christensen [3]. All non-responders and transient responders to resuscitation are subjected to urgent operative exploration.

All responders and stable patients are examined clinically and selectively investigated. Antibiotics are only administered if a

Demographics and mechanism of injury

Over the 46-month study period, 510 patients, (452 males and 58 females) were managed for PNI. The mean age was 29.2 years (range 8–73 years). A total of 452 (89%) patients sustained stab wounds (SW) and 58 (11%) sustained gunshot wounds (GSW). A total of 202 (40%) patients sustained an isolated PNI, whilst 308 (60%) patients sustained trauma to at least one other additional anatomical region. This was for the majority of patients due to concomitant extra-cervical penetrating wounds.

Anatomical site of neck wound

A total of

Discussion

Our data suggests that SNOM of PNI remains an appropriate strategy and the results of our study are comparable to the published literature from both South Africa and North America. Table 7 summarizes the historical publications on PNI and attempts to contextualize our results. Our rate of CTA imaging (76% of all patients) is much higher than that reported in previous studies. This reflects changes in technology and that non-invasive CTA has replaced CDA. This has in our institution resulted in

Conclusion

SNOM of PNI remains a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity is associated with a low yield. CTA has a high false positive rate of thirteen

Conflicts of interest

The authors declare that there are no conflicts of interest.

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Double trouble! penetrating injury to the internal carotid artery and internal jugular vein repaired with non-reversed saphenous vein interposition graft: A case report
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Vascular injury occurs in 6–20 % of penetrating neck trauma and is associated with high rates of morbidity and mortality. Stroke secondary to carotid dissection and/or thromboembolism can have devastating consequences and arterial reconstruction to maintain cerebral perfusion is preferrable to ligation. We describe the management of a single stab injury to Zone III of the neck causing a combined arterial-venous injury.
A 32-year-old man on Rivaroxaban for an unprovoked pulmonary embolism presented in Class III haemorrhagic shock with a single stab wound to the apex of the anterior triangle of the neck. He was alert and neurologically intact on arrival with hard signs of vascular injury. CT-Angiography identified a large pseudoaneurysm of the ICA, sternocleidomastoid haematoma and an arteriovenous fistula. After initial deliberation about a temporising endovascular approach, the patient was taken to theatre for neck exploration. The transected internal jugular vein was ligated and the internal carotid artery was repaired with a non-reversed interposition saphenous vein graft. The patient had a perioperative stroke in watershed territory, likely secondary to hypotension and vasospasm, but was discharged two weeks post-operatively with no deficits.
This rare injury requires an individualised approach and both open and endovascular techniques can be considered. As the carotid was transected, we feared a wire passed antegrade across the defect may become extraluminal, and opted for open repair. Considering this patient's young age, underlying prothrombotic tendency and the contaminated operating field, we decided autologous vein would be preferable to a synthetic conduit for reconstruction.
5-Year management and outcomes of penetrating neck injury in a trauma center. Penetrating neck injury
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Citation Excerpt :
There were no statistically significant differences between the SW, GSW groups and hard and soft signs. As for our primary objective, prevalence of neck surgical exploration without vascular injury was slightly higher (49% vs. 40%) than literature.13 We highlight the importance of not performing neck explorations in all patients who present a penetrating injury.
Penetrating neck injuries represent 5–10% of all traumatic injuries, these bring with them a high rate of morbidity and mortality due to vital structures that could be injured in this area. The aim of this study was to determine the epidemiological and clinical characteristics of penetrating neck injuries.
This was a retrospective, unicentric and descriptive study that included all patients who underwent neck exploration surgery.
A total of 70 neck exploration cases were reviewed, 34 (49%) didn’t had any injury. Thirty (43%) had at least one hard sign, 42 (60%) patients showed at least one soft sign. Statistical analysis showed only surgical time (252 ± 199.5 vs. 155 ± 76.4; p = 0.020) and transfusions (1.87 ± 3 vs. 0.4 ± 0.856; p = 0.013) were statistically significant. We report a mortality of 2 (3%) patients.
Our prevalence of neck surgical exploration without vascular injury was slightly higher (49% vs. 40%) than literature. We highlight the importance of not performing neck explorations in all patients who present a penetrating injury. We did not obtain differences between groups for hard signs and soft signs. We were not able to identify whether or not there would be an injury based on clinical characteristics. Imaging studies should be performed to avoid unnecessary neck explorations; however, depending on the clinical scenario some surgery cannot be avoided.
Las lesiones penetrantes de cuello representan entre el 5-10% de todas las lesiones traumáticas, estas traen consigo una alta tasa de morbimortalidad por estructuras vitales que podrían lesionarse en esta área. El propósito de este estudio fue determinar las características epidemiológicas y clínicas del trauma penetrante de cuello.
Estudio retrospectivo, unicéntrico y descriptivo que incluyó a todos los pacientes sometidos a cirugía de exploración de cuello.
Se revisaron un total de 70 casos de exploración de cuello, 34 pacientes (49%) no presentaron ninguna lesión. Treinta pacientes (43%) tenían al menos un signo duro, 42 pacientes (60%) mostraron al menos un signo blando. El análisis estadístico mostró que solo el tiempo quirúrgico (252 ± 199,5 vs. 155 ± 76,4; p = 0,020) y las transfusiones (1,87 ± 3 vs, 0,4 ± 0,856; p = 0,013) fueron estadísticamente significativas. Reportamos la mortalidad de 2 pacientes (3%).
Nuestra prevalencia de exploración quirúrgica de cuello sin lesión vascular fue ligeramente superior (49 vs. 40%) que la literatura. Destacamos la importancia de no realizar exploraciones de cuello en todos los pacientes que presentan una lesión penetrante. No obtuvimos diferencias entre grupos para signos duros y signos blandos. No pudimos identificar si hubiera o no una lesión en función de las características clínicas. Se deben realizar estudios de imagen para evitar exploraciones innecesarias del cuello; sin embargo, dependiendo del escenario clínico, no se pueden evitar algunas cirugías.
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After careful debridement, smaller defects can be repaired primarily whereas larger defects can be repaired with patch angioplasty or insertion of an interposition autologous vein, allogeneic biologic tissue, or polytetrafluoroethylene graft. Several other uncommon options for repair are found in the literature, including ligation and transposition of the external carotid artery.1,2,24,25 The data in this review are unique from previous studies assessing PCI because of the ability to successfully compare propensity-matched groups based on presenting hemodynamic and injury-related factors.
Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management.
Data from the National Trauma Data Bank from 2002–2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching.
Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P < 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P < 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P < 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P < 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P < 0.001). There were no differences in outcomes relating to surgical approach.
These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient—for example, based on presenting characteristics and the location of the injury.
Diagnosis, management and treatment of neck trauma
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Las lesiones cervicales traumáticas suponen un 5-10% del total de las lesiones traumáticas y acarrean una alta tasa de morbimortalidad, debido a que varias estructuras vitales pueden resultar dañadas. En la actualidad existen varias corrientes de tratamiento, basadas en el manejo inicial por zonas, manejo inicial no basado en zonas y el manejo conservador de pacientes seleccionados. El objetivo de esta revisión sistemática es describir el tratamiento de las lesiones cervicales traumáticas.
Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.
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An audit of penetrating neck injuries in a South African trauma service

Abstract

Introduction

Methodology

Results

Conclusion

Introduction

Section snippets

Methodology

Management of PNI

Demographics and mechanism of injury

Anatomical site of neck wound

Discussion

Conclusion

Conflicts of interest

Injury

Eur J Vasc Endovasc Surg

Penetrating wounds of the neck

J Trauma

Penetrating wounds of the neck

Am J Surg

Evaluation and treatment of penetrating cervical injuries

J Trauma

Penetrating injuries of the neck: a prospective study of 108 patients

Br J Surg

Selective management of penetrating neck injuries. A prospective study

Arch Surg

Penetrating injuries of the neck

Ann R Coll Surg Engl

Physical examination and selective conservative management in patients with penetrating injuries of the neck

Br. J Surg

Evaluation of penetrating injuries of the neck: prospective study of 223 patients

World J Surg