Penetrating Neck Injuries Research Articles

An approach to accurate computed tomography imaging interpretation in penetrating neck trauma.

Penetrating neck injury can have potentially devastating consequences due to the many vital structures contained within the neck. In patients who do not require immediate surgery, computed tomography angiography of the neck is the test of choice to characterize the injury. A systematic approach to assessment will ensure a thorough evaluation and give the reporting radiologist the best chance of identifying the significant findings, which can often be subtle. Clear communication with the trauma team at both the time of request and after the imaging has been evaluated to relay any significant findings is vital to ensure the best outcome for the patient.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries.

Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test

BackgroundThere are many high-volume trauma centers in limited resource environments where a thorough clinical examination of patients may contribute to a more economical, accurate, and widely applicable method of determining the proper management of patients with penetrating neck injuries. The purpose of this study was to validate thorough physical examination as a reliable diagnostic tool in these patients.MethodsWe performed an observational retrospective study of a diagnostic accuracy test where we compared clinical findings (symptoms and soft signs on admission of the patient) with the definitive findings according to the gold standard test for each particular situation (selective studies, clinical observation and surgical exploration). The study was conducted at Hospital Occidente Kennedy (HOK) between August 2009 and June 2010.ResultsThe sample consisted of the clinical records of 207 (n = 207) patients who went to the emergency room for penetrating neck wounds at Hospital Occidente Kennedy (HOK). Of the total sample, 36.2% (n = 75) of patients were considered “asymptomatic” as they didn’t present with any soft signs of injury. Vascular soft signs were present in 57% (n = 118) of the patients, soft signs of the airway and the upper gastrointestinal tract were present in 15.9% (n = 33) and 21.3% (n = 44) of the patients respectively. The sensitivity and negative predictive value (NPV) of any soft sign to determine injuries which require surgical repair was 97.4% [CI] [86.5–99.5%] and 98.7% [CI] [92.8–99.8%] respectively, with a range of confidence [CI] of 95%.ConclusionsOur study’s main findings suggest that patients with neck injuries and no vascular, airway, or gastrointestinal soft sign can be safely managed with a conservative approach. It is important to emphasize the value of the clinical examination since there are many contexts in the modern world where a considerable amount of the population is afflicted by neck trauma and treated under conditions where technological resources are limited.

The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study.

PurposeRecently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the “no zone” approach in traumatic neck injuries.MethodsMedical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the “zone” and/or no zone approach.ResultsOut of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55–157.60).ConclusionTraumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.

Penetrating neck injury with consequential thoracic complications managed with use of video-assisted thoracoscopic surgery: A case report

Introduction. Penetrating injuries of the neck are potentially life-threatening conditions. They can cause injuries of larynx, trachea, esophagus and major blood vessels in this area. Case report. The patient was a 28-year-old male who was stabbed with broken glass penetrating the front side of the base of his neck. The patient had dyspnea and the wound was inflicted the night before admission to hospital. An otorhinolaryngologist found a stab wound in the region of the left basis of the neck. The wound was 2 cm long with no signs of bleeding and deep injuries of the anatomical structures of the neck. However, since left hemopneumothorax was clinically and radiologically apparent, drainage of the thorax was performed upon admission to the intensive care unit. Initially, 400 mL of hemorrhagic effusion was evacuated. However, 24 hours later the patient became hemodynamically unstable. It was an indication for videoassisted thoracoscopy (VATS). Therefore, VATS was used as a diagnostic method in order to determine the nature of the injury. Intraoperatively, we treated a laceration of pleuropulmonary adhesion which was continuously bleeding from the apex of the thoracic cavity. As a result, adequate surgical hemostasis was achieved. Furthermore, during the three-week postoperative period, thoracic tubes were placed due to the prolonged air leakage. A thoracic tube was placed laterally along with another one which was placed in intercostal space higher. After total reexpansion of the left lung, thoracic tubes were extracted, and the patient was discharged. Conclusion. Nowadays, VATS has become a highly important ultimate treatment of thoracic trauma. This minimally invasive method allows us to verify injury type and localization, to resolve it and further to follow-up evaluation of pathological changes in the lungs, pericardium, mediastinum, pleura and thoracic wall. In the case of stab wounds in the cervical region, any injuries of the lungs and pleura must be taken into consideration.

Emergent Reconstruction of Laryngeal Penetrating Neck Injury: A Case Report

Objective: This paper aims to describe an unconventional surgical procedure performed in a case of penetrating neck injury involving the larynx.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Government Hospital&#x0D; Population: One&#x0D; Results: A 38-year-old man sustained a hacking laceration to the anterior neck that extended into the hypopharyngeal area, transecting the thyroid cartilage. After pre-emptive tracheostomy, the patient was referred to otorhinolaryngology – head and neck surgery due to the extensive hypopharyngeal injury. Neck exploration performed to control bleeders confirmed a Schaefer-Fuhrman Classification Group 3 penetrating neck injury. Anastomotic reconstruction of the hypopharynx, transected thyroid cartilage and strap muscles was attempted using absorbable sutures with post-operative re-establishment of structural continuity and documentation of full bilateral vocal fold mobility. The patient was about to be discharged home with a tracheotomy and nasogastric tube when he suddenly deteriorated and expired on the eighth post-operative day.&#x0D; Conclusion: Our technique might be utilized in cases where urgent reconstruction of laryngeal structures is considered despite serious damage to the laryngeal skeleton, and may provide a temporary surgical option for similar cases in an emergent setting. However, we cannot recommend it as a routine standard on the basis of one case.&#x0D; Keywords: larynx; penetrating neck injury; vocal cord; reconstruction, neck exploration

The anaesthetic management of the airway after blunt and penetrating neck injury

The anaesthetic management of the airway after blunt and penetrating neck injury

Penetrating neck injuries with laryngeal framework involvement: in a tertiary care centre

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Penetrating neck injuries are very common as a mode of homicidal and suicidal injuries. Not many of them are deep enough to affect the laryngeal framework.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Prospective study in the Department of ENT Stanley Medical College, Chennai. The study period was from January 2018 to December 2018. Follow up of 3 months was done.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Penetrating neck injuries treated on emergency care with tracheostomy and wound exploration and repair. It was found to be more common in young male population.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Laryngeal framework involvement necessitates tracheostomy during wound exploration. On table laryngeal injury repair improves prognosis and early post-operative vocal fold assessment helps frame a treatment plan designed specifically for the patient.&lt;/p&gt;

Bougie-facilitated Intubation in Penetrating Neck Injury

Bougie-facilitated Intubation in Penetrating Neck Injury

Penetrating neck trauma: radiological predictors of vascular injury.

Vascular injury in penetrating neck trauma predicts a poorer outcome and usually requires surgical neck exploration. Multi-detector computed tomography (MDCT) angiography is a readily available non-invasive diagnostic tool that can identify direct and indirect signs of vascular injury in stable patients. This study aims to investigate the diagnostic accuracy of radiological signs of vascular injury on MDCT, and their implications on patient management in the setting of penetrating neck trauma. A retrospective cohort study of penetrating neck injuries (PNI) between 2012 and 2018 in a UK major trauma centre was performed. Clinical data and operative findings were compared with radiological findings on MDCT performed at the time of admission. 157 patients were identified with PNI in the study period, with 67 meeting inclusion criteria. The predictive value of indirect radiological signs of vascular injury alone was low, with only 12.1% of these patients having significant vascular injury found at neck exploration. However, the combined use of direct radiological signs with clinical signs resulted in a specificity of 97.7% for vascular injury. The use of direct and indirect radiological signs of vascular injury can increase the accuracy of diagnosis when used in conjunction with clinical signs. Combining clinical assessment and radiological investigation, specifically contrast-enhanced MDCT, improves the specificity in pre-operative assessment of potential vascular injury in PNI. MDCT is recommended in stable patients with clinical signs of vascular injury to reduce the rate of negative neck exploration.

Foley catheter balloon tamponade for penetrating neck injury management in military medicine: a case report

Background&#x0D; The use of Foley catheter balloon tamponade (FCBT) to address bleeding in the neck and maxillofacial area associated with penetrating trauma is widely accepted in South African Emergency Departments. Its efficacy has been documented in combat settings in the Iraqi area of operations, with significant improvement of patients survival rate. Despite such evidence, Special Operations Forces (SOF) medics training in these techniques is limited.&#x0D; Case&#x0D; We present the case of a partner forces (PF) soldier that received shrapnel injuries during combat operations, resulting in life-threatening haemorrhage from the neck.&#x0D; Conclusion&#x0D; The Special Operations Forces medics who treated this patient decided to apply FCBT to prevent re-bleeding during an unsupervised ground vehicle movement to the host nation (HN) definitive care. None of the SOF medics involved had received formal training in the technique prior to the case. Their only knowledge was based on anecdotal evidence and self-study of the literature. Due to the lack of accountability by admitting a patient into the HN chain of care, there is no information on the outcome other than the patient survived. FCBT was performed after the wound was packed ineffectively with hemostatic gauze resulting in an unstable clot that failed with patient movement resulting in a probable carotid artery Zone I I neck bleed. FCBT has the potential to be a quick and effective adjunct to control bleeding in the complicated narrow track wound patterns in the neck and maxillofacial area that are not amenable to manual pressure or hemostatic agents in combat trauma medicine.&#x0D; Keywords&#x0D; Foley; Foley catheter balloon tamponade; Special Operations forces Medics; Bleeding.&#x0D;

Penetrating neck trauma with common carotid artery injury caused by a percussive drill

Rationale:Penetrating neck traumas are dangerous and have a high mortality rate, particularly in patients with common carotid artery injuries. Advances in diagnostic imaging technology have shifted management of penetrating neck injuries from mandatory exploration to selective management. The question is now regarding optimal selection of auxiliary examinations to assess “stability” rapidly and guide clinics in managing such patients.Patient concerns:A 56-year-old man suffered neck trauma with the right common carotid artery caused by a percussive drill. The carotid artery could not be clearly displayed in computed tomography (CT) angiography imaging.Diagnoses:Penetrating neck trauma due to percussive drill bit with common carotid artery injury.Interventions:X-ray and bedside duplex ultrasound with color Doppler flow imaging were used to assess the state of trauma and the foreign body was removed under general anesthesia.Outcomes:The patient was discharged at postoperative day 10 with no complication. The patient had no sequelae from this injury at 6-month follow up.Lessons:X-ray provides a comprehensive assessment of damage, and can efficiently detect foreign bodies in the skull and cervical vertebrae. Duplex ultrasound to be a viable method to exclude macrovascular injury in unstable patients who are not eligible for computed tomography angiography (CTA) or catheter angiography imaging. Widely available duplex ultrasound and x-ray should be considered in emergency situations.

GUNSHOT WOUND TO THE NECK: NOT AN EASY AIRWAY

Introduction: Securing the airway is the first and most important part in any trauma as per the Advanced Trauma Life Support (ATLS) guidelines, and an injury to the face and/or neck can lead to devastating results if the airway was not secured. Objective: A penetrating neck injury can be a life-threatening event if the airways were not secured. Case Report: 26 years old female patient was transferred to our Emergency Department (ED) from a rural secondary care facility, for a self inflicted, close range, GSW to the thyroid cartilage by a low velocity firearm. An attempt of oropharyngeal intubation was unsuccessful and as the patient’s saturation was dropping, the surgeon present in the rural ED elected to expand the entry wound and insert the tube directly through the trachea and transfer the patient to our tertiary care center. Conclusion: Securing the airways remains the most critical and challenging part even for the most skilled emergency physicians. At least a second and third alternatives should be prepared and ready in case of failure of intubation.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management – A National Trauma Data Bank Review from 2007 to 2011

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007–2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Neck Injuries: a Complex Problem in the Deployed Environment

Evaluation and treatment of injuries to the neck has received a lot of attention over the past 20 years. New evaluation protocols and treatment recommendations have been developed. The goal of this review is to examine these strategies and evaluate their suitability for treatment of patients in a deployed setting. Studies from several large trauma centers have changed common practice with regard to both penetrating and blunt neck injuries. The requirement to explore all zone II neck injuries has largely been replaced by a selective exploration based on physical examination and imaging. Also, blunt cerebrovascular injuries, once thought to be rare, have been demonstrated to be common and treatment dramatically reduces the morbidity and mortality. Injuries to the neck are a significant problem in the deployed environment. The blast injuries that are common in Iraq and Afghanistan produce multiple injured casualties. In addition to injuries to other body regions, injuries to the neck can involve both blunt and penetrating mechanisms as well as injuries to the spinal column. The extent and outcome of these complex injuries has not been fully evaluated and would remain an area worthy of study.

Penetrating Cervical Vascular Injuries

This article reviews penetrating cervical vascular injuries, with a focus on the initial control, diagnostic workup, and operative or endovascular management. The review highlights the change in management approach from one based on anatomical zones of the neck to the contemporary approach of using physical exam and computed tomographic angiography to guide decision making. The approach to penetrating neck injuries has evolved over the past 40 years with a resultant decrease in the rate of non-therapeutic operations, driven primarily by improvements in imaging technology. The role of endovascular techniques is now established for vertebral artery injuries and continues to evolve for non-emergent carotid injuries. Penetrating cervical injuries pose a significant risk to life and triage of patients to the operating room or further imaging by computed tomographic angiography (CTA) must occur promptly based on the physical examination. In the operating room, the management of complex venous injuries consists of simple ligation. Vertebral injuries can be temporized with packing or bone wax and then managed with percutaneous endovascular interventions. Carotid injuries may generally be managed with arteriorrhaphy, primary repair, or reconstruction with venous or PTFE graft. In damage control situations, shunting is preferred.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage inaPerfused Human Cadaver Model.

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate. We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT). Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded. There was no significant difference between the fluid loss/no movement (p>0.450) and fluid loss/movement (p>0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p>0.000) and movement (p>0.000). The iTClamp was also significantly faster to apply than the Foley (p>0.000). The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Surgical treatment of foreign body embolus in the Middle cerebral artery secondary to neck injury

Background: We report a case of a foreign body embolus to the middle cerebral artery and reviewed similar cases previously reported. Methods: A 30-year-old man was seen 72 days after a penetrating neck injury with a 1-month history of numbness in the left limb and impairment of the fine movement in the left hand. Radiological examination revealed a foreign body in the M2 portion of the right middle cerebral artery (MCA). The patient received arteriotomy and in situ suturing. Results: During the operation, we found a metallic foreign body at the bifurcation of the M2 upper trunk of the right MCA, narrowed distal blood vessels and thinned vessel walls. The foreign body was surrounded by granulation tissue. Both foreign body and granulation tissue were removed slowly followed by in situ suturing. Indocyanine green angiography confirmed arterial patency. Three days after the surgery, the patient developed numbness and weakness in the left arm, with a muscle strength of grade 4. Computed tomography showed partial infarction in the right temporal lobe. Then, antispasmodic drugs were used. Muscle strength recovered by 14 days after the operation. Conclusions: In the subacute stage, surgery can be conducted to remove intra-arterial foreign bodies along with their surrounding granulation tissue if computed tomography perfusion suggests a decreased blood flow reserve capacity.

Penetrating Neck Trauma: a Review

This review focuses on the management of penetrating neck trauma and its evolution over the last several decades. Our increased experience with high-resolution computed tomography has changed the management of penetrating neck trauma from an anatomically zone-based approach to a “no zone” approach. Physical signs and symptoms of vascular, airway, and digestive track injuries still guide the basis of further radiographic and surgical workup. With the advancement and greater availability of multi-detector computed tomography (MDCT) technology, assessment of injuries has become easier and far more accurate. The hemodynamically stable patient may now be approached in a “no-zone” manner, and in certain cases managed safely with conservative measures. Wartime experience and improved technology played major roles in the evolution of penetrating neck injury management. Aggressive surgical exploration had given way to selective management based on anatomical neck zones, to most currently a “no zone” approach.

Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care: iTClamp Mechanical Wound Closure Device TCCC Guidelines Proposed Change 19-04 06 June 2019.

The 2012 study Death on the battlefield (2001-2011) by Eastridge et al.1 demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat wounded personnel will receive a head or neck wound. The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound. The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp's unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications. The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training, and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods. The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with a CoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial injuries and penetrating neck injuries with external hemorrhage.