Mandatory Exploration Research Articles

Reduced Dependency on Arteriography for Penetrating Extremity Trauma

Indications for arteriography in penetrating extremity trauma remain controversial. We reviewed our clinical experience in 454 patients (514 extremities) with penetrating trauma admitted during a prior 3 1/2-year period. Injuries were caused by stab wounds in 60 (11.7%) extremities and by gunshot wounds in 454 (88.3%) extremities. Thirty-three of the 60 stab wounds (55%) required u rgent exploration, and 27 underwent arteriography. No arteriograms were positive for unsuspected arterial injury in this group. Forty-two of 454 gunshot wounds (9.3%) underwent mandatory exploration; arteriograms were performed on 412 extremities. Forty-four arteriograms (10.7%) demonstrated evidence of unsuspected arterial injuries. During the last year, randomly selected extremities (n = 23) have been studied with B-mode ultrasonography and segmental Doppler pressure measurements. Using the subsequent arteriography as the “gold” standard, sensitivity was 83% and specificity was 100%. Gunshot wounds were categorized according to location and positive arteriograms. Injuries to the lateral thigh and arm resulted in no positive arteriograms, while positive studies were observed in 11% of medial and posterior arm, 14% of antecubital fossa, 25% of forearm, 7.5% of medial and posterior thigh, 8% of popliteal fossa, and 26% of calf injuries. We recommend arteriography for gunshot injuries to identified high-risk areas, while clinical evaluation alone is accurate in all stab wounds to the extremities and gunshot wounds to the lateral thigh and outer arm. Preliminary data suggest expanded use of B-mode ultrasonography may further reduce our dependency on arteriography in these cases.

Penetrating extremity trauma: Identification of patients at high-risk requiring arteriography

Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper arm wounds and stab wounds to the extremities.

Penetrating neck trauma: Mandatory versus selective exploration

The management of penetrating neck wounds has been the subject of great interest and controversy over the years. The policy of mandatory exploration of all wounds penetrating the platysma originates from experience with military injuries. Current figures show little change since the Vietman War. Currently one half of all deaths are attributed to spinal cord injuries or thrombosis of the common or internal carotid arteries leading to CNS infarction

REDUCED DEPENDENCY ON ARTERIOGRAPHY FOR PENETRATING EXTREMITY TRAUMA (PET)

Indications for arteriography in penetrating extremity trauma remain controversial. We reviewed our clinical experience in 454 patients (514 extremities) with penetrating trauma admitted during a prior 3 1/2-year period. Injuries were caused by stab wounds in 60 (11.7%) extremities and by gunshot wounds in 454 (88.3%) extremities. Thirty-three of the 60 stab wounds (55%) required urgent exploration, and 27 underwent arteriography. No arteriograms were positive for unsuspected arterial injury in this group. Forty-two of 454 gunshot wounds (9.3%) underwent mandatory exploration; arteriograms were performed on 412 extremities. Forty-four arteriograms (10.7%) demonstrated evidence of unsuspected arterial injuries. During the last year, randomly selected extremities (n = 23) have been studied with B-mode ultrasonography and segmental Doppler pressure measurements. Using the subsequent arteriography as the "gold" standard, sensitivity was 83% and specificity was 100%. Gunshot wounds were categorized according to location and positive arteriograms. Injuries to the lateral thigh and arm resulted in no positive arteriograms, while positive studies were observed in 11% of medial and posterior arm, 14% of antecubital fossa, 25% of forearm, 7.5% of medial and posterior thigh, 8% of popliteal fossa, and 26% of calf injuries. We recommend arteriography for gunshot injuries to identified high-risk areas, while clinical evaluation alone is accurate in all stab wounds to the extremities and gunshot wounds to the lateral thigh and outer arm. Preliminary data suggest expanded use of B-mode ultrasonography may further reduce our dependency on arteriography in these cases.

The necessity of mandatory exploration of penetrating zone II neck injuries: Bishara RA, et al. Surgery 1986;100:655–658

To reevaluate the validity of our policy of mandatory surgical exploration of penetrating zone II neck injuries, the charts of 110 patients who underwent surgical exploration for such injuries were reviewed. Fifty-three percent of the patients had normal findings at exploration, whereas 33% had injuries involving vascular structures of the neck and 14% had nonvascular injuries. Injuries were not suspected on clinical grounds preoperatively in 23% of the patients in whom surgical exploration revealed injury. The injuries most likely to escape preoperative diagnosis were isolated venous injuries and isolated pharyngoesophageal injuries. Arteriography yielded false-negative results in two arterial injuries. No deaths and only a 5% incidence of minor complications occurred in the group with no injuries detected at exploration. We conclude that surgical exploration of penetrating zone II neck injuries is safe and appropriate.

Mandatory vs Selective Exploration for Penetrating Neck Trauma

To determine the optimal management of patients with penetrating wounds to zone II of the neck, we performed a prospective evaluation of 120 consecutive patients with such injuries, correlating the results of clinical and diagnostic examinations with operative findings. Seven patients presenting with life-threatening hemorrhage from the neck wound were operated on immediately; the remaining 113 patients underwent arteriography, laryngotracheoscopy, esophagoscopy, and esophagography, followed by neck exploration. Forty-eight major injuries were identified in 35 neck explorations. Five patients were identified with clinical and diagnostic findings that were considered normal preoperatively; however, at operation six major injuries were found in these patients. This study indicates that potentially lethal injuries to major vascular and visceral structures in the neck may go undetected if selective exploration criteria are used in the decision to explore penetrating wounds to zone II of the neck.

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck : Noyes LD, McSwain NE Jr, Markowitz IP, et al. Ann Surg 204:21, 1986

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck : Noyes LD, McSwain NE Jr, Markowitz IP, et al. Ann Surg 204:21, 1986

Penetrating neck wounds: Mandatory versus selective exploration

Penetrating neck wounds: Mandatory versus selective exploration

Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck.

Of 193 patients with penetrating wounds of the neck, 76 had only surgical exploration; 57 had only nonsurgical exploration including one or more of the following: arteriography, bronchoscopy, laryngoscopy, esophagoscopy, and contrast-swallow esophagogram; and 60 had both surgical and nonsurgical exploration. Eighty-six patients were wounded by gunshot, 108 by stabbing. Presenting signs and symptoms were an unreliable method of predicting presence or absence of injury. Overall negative rate of surgical exploration was 50% (54% of the stabbings and 45% of the gunshots). Accuracy of nonsurgical exploration was assessed by comparing to surgery. Arteriography was 100% accurate, a combination of bronchoscopy and laryngoscopy was 100% accurate, contrast-swallow esophagogram was 90% accurate, and esophagoscopy was 86% accurate. The literature was reviewed regarding the accuracy of nonsurgical as well as surgical exploration. The one complication attributed to nonsurgical exploration was a symptomatic anemia, while there were two wound infections resulting in increased length of stay associated with negative surgical exploration. Overall mortality rate was 5.6%. The average length of stay for nonsurgical exploration only was 2.8 days, for negative surgical exploration was 4.2 days, and for positive surgical exploration was 9.5 days. Financial cost of a negative surgical exploration was $3185, while for four-vessel cerebral arteriography with panendoscopy it was $3492. More studies need to be done, particularly concerning venography and esophagoscopy. However, considering the fact that surgical exploration should by no means be considered 100% accurate, the data in this study support the fact that arteriography with panendoscopy represents an equally safe and acceptable method of exploration of penetrating wounds of the neck for stable patients without specific signs and symptoms of injury and can be expected to result in a reduced number of negative surgical explorations and their associated morbidity as well as a reduced length of hospital stay, although at a slightly higher financial cost when compared to mandatory surgical exploration.

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck

The Journal of Trauma: Injury, Infection, and Critical Care: February 1986 - Volume 26 - Issue 2 - p 202

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck: Obeid FN, Haddad GS, Horst MH, et al Surg Gynecol Obstet 160:517–521 Jun 1985

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck: Obeid FN, Haddad GS, Horst MH, et al Surg Gynecol Obstet 160:517–521 Jun 1985

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck: Obeid FN, Haddad GS, Horst HM, et al Surg Gynecol Obstet 160;517–522 Jun 1985

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck: Obeid FN, Haddad GS, Horst HM, et al Surg Gynecol Obstet 160;517–522 Jun 1985

Nonoperative Management of Renal Stab Wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3).The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and O per cent in group 3.Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3.Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively.Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.

110 bullet wounds to the neck.

Selective management of 110 patients with bullet wounds to the neck resulted in 31 explored and 79 observed. There was an overall mortality rate of 2.7%, well within that reported in the literature, which ranges from 2 to 6%. At our institution, it is believed that a substantial number of patients can be selectively managed, depending on the signs and symptoms, the site and direction of the trajectory, and whether the interval of time between injury and entrance to the hospital is longer than 6 hours. Patients who are stable and lack physical signs of obvious major neck injury are evaluated by diagnostic radiologic and endoscopic techniques. If no significant injury is found, they are admitted for observation. The efficacy of this mode of management is strengthened by savings in the costs of hospitalization, risks of undergoing an additional operation, overall negative exploration rate in the mandatory exploration studies, and our own results of selective management. We do not recommend this form of management for all institutions. It has been found that in this well-staffed teaching hospital with an extensive trauma service, experienced personnel doing careful and repeated physical examinations, in addition to 24-hour availability of radiologic and endoscopic modalities, the policy of selective management of bullet wounds to the neck can be adhered to. Further studies need to be done into the various mechanisms of penetrating neck trauma, separating each mechanism into morbidity, mortality, and treatment.

Initial management of penetrating neck wounds-a selective approach

The management of anterior penetrating neck injuries remains highly controversial. This is a review of our treatment of such injuries over the preceding decade. During the first 6 years all injuries were explored. Of 75 patients explored, only 33 (44%) had significant injuries. During the last 4 years, patients were managed selectively. Patients with bleeding, crepitation, dysphagia, compromised airways, or for whom full clinical evaluation was not possible underwent prompt formal operative exploration. All other patients were observed. Of 48 patients who underwent explorations, 41 (85%) had significant injuries. Thirty-six patients were observed with no adverse sequelae. Ancillary diagnostic testing was only routinely done in level I injuries. Over the last 10 years we evolved from mandatory exploration to selective exploration of anterior penetrating neck injuries. Our experience confirms the safety and cost-effectiveness of a selective exploration policy. Furthermore, observation does not mandate extensive ancillary diagnostic testing for level II and level III injuries.

Selective management of penetrating neck trauma. Cost implications.

Many authors advocate mandatory surgical exploration for all patients with penetrating neck trauma, while other maintain that with careful diagnostic evaluation some patients safely can be spared an operation. From our hospitals, 65 cases of penetrating neck trauma were reviewed, 27 of which showed no mortality without operation. Surgical exploration of the neck showing no injury added $1,930 to the cost of hospitalization. Review of the surgical literature discloses that mortalities reported by authors advocating selective and mandatory exploration are similar. The incidence of missed significant injury is low among patients observed selectively. A management algorithm for the diagnostic evaluation and treatment of patients with penetrating neck trauma is advocated. All stable patients should undergo four-vessel angiography. Studies of the cervical esophagus may be performed. Patients with entirely normal diagnostic evaluations may be observed safely, sparing unnecesary operation.

Penetrating neck wounds

A review of 68 cases of penetrating neck wounds from our institution as well as a review of the recent literature dealing with the management of such injuries is presented. The wounding agent was gunshot (38 cases), knife (21), broken glass (3), an ice pick (1) and miscellaneous (5). Presenting findings were hematoma (20 patients), neurologic deficit (13), shock (8), pneumo- or hemothorax (7), subcutaneous emphysema (7), bruit (2) and no major findings in 24 patients. Of the 68 patients, 19 were managed nonoperatively with only one complication. The remainder of the group underwent exploration, with negative results in 26 patients or 67 percent. Positive findings at operation included major vascular injuries in nine patients, esophageal injuries in six and tracheal injury in three. We conclude from our experience and a review of the literature that mandatory exploration is not required in all penetrating neck injuries. Current indications for surgery at our institution include all gunshot wounds and other wounds associated with one or more of the following: shock, significant hematoma, active bleeding, hemoptysis, hematemesis or subcutaneous emphysema. Close observation for 48 hours is indispensible in all patients managed nonoperatively. Ancillary procedures such as arteriography, esophagoscopy, barium swallow and bronchoscopy are valuable diagnostic procedures in selected cases. Careful examination of the pharynx, esophagus and trachea should be carried out in all observed patients.

Penetrating neck injury : Saletta J. D., Lowe R. J., Lim L. T., Thornton J., Delk S. and Moss G. S. (1976) Penetrating trauma of the neck. J. Trauma16, 579

Penetrating injury of neck is a complicated pathology, and there is more than one opinion of its treatment tactic in nowadays. Our recomendation is to refuse mandatory surgical exploration. There are found some recomendations to refuse routinely performed mandatory explorations, with suggestions of active observation of patients. The results of scientific studies showed, that there is no difference between those two models of treatment and observation. In cases with possibilities of full investigation of patients (panendoscopy, X-ray investigations, ultrasound investigations, angiography), we suggest the model of active observation. If there are no possibilities of full investigation, we prefer mandatory surgical exploration.

Gunshot wounds of the abdomen

• During a five-year period from July 1968 through June 1973, 277 abdominal gunshot wounds (GSWs) occurred, the overall fatality of which was 10%. Abdominal exploration was done in all patients. No intra-abdominal injury was found in 40 patients (14%) and no death occurred in this group. There were 28 fatalities (12%) in 237 patients (86%) who had intra-abdominal injuries. Morbidity and mortality were related not only to the number of organs injured, but also to specific organs injured. The leading cause of early death was hypovolemia due to major vessel injuries. Septicemia was the most common cause of death if the patient survived the first 24 hours of hospitalization. Penetrating abdominal stab wounds and gunshot wounds must be considered separately, and mandatory routine abdominal exploration for all penetrating gunshot wounds is advised. In stab wounds to the abdomen, conservative management may be preferable. ( Arch Surg 111:862-865, 1976)

Gunshot Wounds of the Abdomen

During a five-year period from July 1968 throuhgh June 1973, 277 abdominal gunshot wounds (GSWs) occurred, the overall fatality of which was 10%. Abdominal exploration was done in all patients. No intra-abdominal injury was found in 40 patients (14%) and no death occurred in this group. There were 28 fatalities (12%) in 237 patients (86%) who had intra-abdominal injuries. Morbidity and mortality were related not only to the number of organs injured, but also to specific organs injured. The leading cause of early death was hypovolemia due to major vessel injuries. Septicemia was the most common cause of death if the patient survived the first 24 hours of hospitalization. Penetrating abdominal stab wounds and gunshot wounds must be considered separately, and mandatory routine abdominal exploration for all penetrating gunshot wounds is advised. In stab wounds to the abdomen, conservative management may be preferable.