Penetrating Neck Injuries Research Articles

Penetrating neck injuries involving the larynx: A report of three cases

Penetrating neck injuries involving the larynx: A report of three cases

A novel method of airway management in a case of penetrating neck injury.

Direct injury to airway is a rare event and also a challenge to anaesthesiologist and surgeon. We present a case report of open tracheal injury with right pneumothorax in a young male following assault with a sharp weapon. In spite of a chest tube in situ, the patient came with collapse of one lung and tachypnoea which required surgical exploration. Lower airway was evaluated by fibre-optic bronchoscopy through the open tracheal wound while he was awake and tracheal tube was passed over the bronchoscope. There was no vascular or oesophageal injury detected. Although there was a pleural tear, there were no signs of injury to lung parenchyma. After evaluation, end to end anastomosis of the trachea was planned, for which orotracheal tube was passed with surgical assistance. Patient was shifted to post-operative high dependency unit and was electively ventilated for 7 days and was later successfully extubated under fibre-optic bronchoscope guidance.

English

Penetrating neck injuries constitute 5%–10% of all trauma cases. Such injuries are dangerous because of the high risk of injury to the vital structures in the neck and hence demand an immediate surgical exploration. We present a case of a penetrating injury of the neck caused by the broken metallic fragment at work place.

Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm

To determine the specific CT findings of penetrating neck wound profile predicting aerodigestive injuries, diagnostic performance of CTA and to propose a modified selective management algorithm to reduce nontherapeutic invasive procedures. We retrospectively evaluated CTAs of 102 patients to determine the presence of various CT signs. "Trajectory"-based signs included trajectory of the wound extending into the aerodigestive tract and trajectory violating the deep neck spaces. "Conventional" signs included transcervical injury; wall defect; air or blood in the deep neck spaces; irregular or thickened aerodigestive tract; and active mucosal bleeding. Trajectory of the wound extending into the aerodigestive tract (sensitivity 76%, specificity 97%) and trajectory of the wound violating the suprahyoid deep neck spaces or the infrahyoid visceral space (sensitivity 97%, specificity 55%) were the best predictors of injury on regression analysis. The most specific "conventional" CT signs were "wall defect" and "active mucosal bleed", but had very low sensitivity. The sensitivity of CTA for detecting an injury ranged from 89.5% to 92%, specificity ranged from 62.5% to 89%. CTA can be a useful technique in detecting aerodigestive injury. Our proposed management algorithm can exclude an injury with high degree of confidence (sensitivity 97%). • Trajectory-based CT signs predict aerodigestive injury after penetrating neck trauma. • Surgery should be considered when trajectory extends into the infra-arytenoid aerodigestive tract. • Endoscopy or exploration should be considered when trajectory violates deep neck spaces. • This modified approach can decrease negative explorations and invasive diagnostic procedures.

Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography.

The purposes of this study were to assess the diagnostic performance of 40- and 64-MDCT angiography with digital subtraction angiography as the reference standard in the detection of arterial injuries in patients at high risk after penetrating neck trauma and to perform a separate analysis of injuries to the external carotid artery. In a retrospective evaluation of 53 sets of angiograms from 51 patients with penetrating neck injury, three reviewers unaware of the digital subtraction angiographic findings reviewed the CT angiographic (CTA) images to discern the presence or absence of arterial injuries. Sensitivity and specificity of CTA were calculated per injury, and a separate analysis of external carotid artery injuries was performed. Sensitivity of CTA for detecting arterial injuries ranged from 75.7% (95% CI, 62.3-86.9%) to 82.2% (95% CI, 69.5-92.1%). Specificity ranged from 96.4% (95% CI, 94.0-98.4%) to 98.4% (95% CI, 96.0-100%). CTA was highly sensitive for detection of the subgroup of injuries involving the large-caliber vessels that contribute to cerebral circulation. These sensitivities ranged from 92.8% (95% CI, 66-98.8%) to 100% (95% CI, 76.6-100%) for internal carotid artery injuries and from 88.9% (95% CI, 65.2-98.3%) to 94.4% (95% CI, 72.6-99.0%) for vertebral artery injuries. In contrast, sensitivity of CTA was limited for external carotid artery injuries, ranging from 63.4% (95% CI, 45.5-79.5%) to 70.0% (95% CI, 52.0-85.0%). CTA can be used for initial evaluation and may help guide management decisions if an external carotid artery injury is detected. Negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.

Evaluation of the use of tomography in penetrating neck trauma.

the study has the intention of evaluate the accuracy of computed tomography for the diagnosis of cervical lesions on penetrating neck trauma and also identify the most frequent mechanisms of trauma. Most injured structures, determine the age range and the most prevalent sex. observational descriptive retrospective study executed by the systematic retrospective review of medical records of all patients victims of penetrating neck trauma that went through surgery and CT scans, admitted into Hospital do Trabalhador, between January 2009 and December 2013. the final sample was of 30 patients, 96.7% of the male sex, the median age was of 28 years old. Most patients suffered injuries by gun (56.7%) and 33,3% suffered stab wounds. The most stricken area of the neck was Zone II (77.8%) and the left side (55.2%). Regarding the structures injured, the CT showed 6.7% lesions on airways but the surgery showed 40% of damaged, with a value of p=0.002. As to damages of the esophagus and pharynx the CT detected 10% of lesions, while surgery found 30% of lesions, therefore with a significant value of p=0.013. As for the analysis the CT showed reliable. As for the analysis of vascular damage, the CT showed to be, in most cases, reliable to the findings during the surgical act. besides the great use of CT for the diagnosis of penetrating neck injuries we can say that this is an exam with low accuracy for the diagnosis of lesions of aerodigestive tract, therefore it is important a clinical correlation for a good diagnosis.as for the vascular lesions and of other structures, the CT had high sensibility and specificity, thus a good exam to be used in overall.

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

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. 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. 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. 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.

Follow-up Study of Mortality after Clinical Protocol Based Intervention at Emergency of Patan Hospital

Introductions: Decreasing the mortality of patients is one of the major concerns of emergency department. Mortality decreases after implementation of protocol based intervention. This follow up study has been done to see the benefit of protocol based approach. Methods: This was a cross sectional study conducted at emergency department of Patan hospital from January 2013 to June 2013. All records of patient with mortality were reviewed excluding those who were brought dead. Results: Total mortality in six months was 31. Mortality rate was 1.7 per thousand emergency visits. Mean duration of stay at emergency was five hours, range 30 minutes to 25 hours. The common diagnoses at presentation were Pneumonia 12 (45.1%), Upper gastrointestinal tract bleeding 4 (13%), Hypoglycaemia 3 (9.7%) followed by blunt abdominal trauma, penetrating neck injury, pneumothorax, spinal shock, head injury and zinc phosphide poisoning 2 (6.5%) each. The most common causes of death were septic shock 9 (29%), hypovolaemic shock 7 (25.8%), respiratory failure 6 (19.4%), hypoglycaemia 3 (9.7%), cardiogenic shock, raised intracranial pressure and spinal shock 2 (6.5%) each. Conclusions: Protocol based management are important tools to decrease mortality but it is not the only factor that decreases the mortality. Plain Language Summary: This study was done to see if implementing protocol based management improves mortality or not. This study highlighted the fact that protocol based management are important sufficient to decrease mortality. DOI: http://dx.doi.org/10.3126/jpahs.v1i1.13009 Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):13-15

Selective management of penetrating neck injuries using “no zone” approach

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds. A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate. Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%). Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

Penetrating Neck Trauma in a 4-Year-Old Child

Penetrating neck injuries are uncommon in children and a post traumatic common carotid artery to internal jugular vein fistula rarely occurs. We present one case of a 4-year-old girl with a penetrating injury from flying glass fragments in the midportion of the neck, caused by an explosion in a military warehouse. She was referred to our facility upon a request of a hospital of a neighbour country, two days after sustaining a penetrating cervical trauma. The presentation, diagnostic procedures and surgical management of this very rare injury are discussed. No neck penetrating trauma should be underestimated and a selective surgical intervention based on clinical examination and investigation tests findings is associated with good long-term outcomes.

PRISE EN CHARGE DES PLAIES PENETRANTES CERVICALES AU SENEGAL : A PROPOS DE 22 CAS

Introduction: the aim of this study is to assess and discuss the epidemiology, etiology and therapeutic features of our experience in management of penetrating neck injuries. Patients and Methods: It is a retrospective review of the medical records of all Patients whose presented injuries penetrating platysma between January 2002 and December 2006. Age, gender, etiology, wound site, injured structures, treatment, and outcome were analyzed. Results: Twenty two patients were identified. There were 19 males and 3 females. The mean age was 26 years (range, 4 to 40 years). Injuries were caused by stab wounds in all patients. The main location of injury was zone II in 21 cases (95.5%). Sixteen patients (72. 72%) underwent emergent neck exploration. The neck exploration noted a predominance of muscle injuries followed by aerodigestive tract injuries. The overall mortality was 4.54%. Conclusion: Penetrating neck wounds are still a rare disease. For impressive as they are, they keep a good prognosis if they are subject to appropriate care. Keywords: penetrating neck injuries; cervicotomy

Western Trauma Association critical decisions in trauma: penetrating chest trauma.

This is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their

The Use of the Anatomic ‘Zones’ of the Neck in the Assessment of Penetrating Neck Injury

The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as "unexpected" if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

Getting ahead of penetrating neck injuries

Getting ahead of penetrating neck injuries

Getting ahead of penetrating neck injuries.

Getting ahead of penetrating neck injuries.

Multiple-projectile penetrating neck injury from a modified nail-containing gas pistol.

Penetrating neck injuries result from missiles and stab wounds. A gas pistol is a non-lethal weapon for self-defence. We present a case where the use of a modified gun led to multiple injuries in a single shot. Four projectiles were embedded in the neck, one in the larynx and three in the cervical spine. The first was removed via a combined external and endoscopic approach, while the rest were put on follow-up. The reported case shows that damage from modified gas pistols, although rarely life threatening, may cause long term discomfort and diminished quality of life.

Cervical penetrating trauma: literature review

Penetrating neck injuries are a major cause of morbidity and mortality in emergency admissions and surgical emergency services, so it is extremely important the anatomical and functional knowledge of the main structures affected during trauma. This article is a literature review of the major anatomical divisions, besides directing the physician to the diagnosis and best choice through selective management that seeks to identify patients who could benefit from surgical treatment of their wounds in an attempt to decrease the number of operations unnecessary.

Penetrating injury to the neck - Three case reports with review of literatures

Penetrating neck wounds are potentially dangerous and require emergency management because of the presence of vital structures in the neck. Organic foreign bodies further carry a risk of wound infection. Three interesting penetrating neck injury with foreign bodies are presented of which two are metallic, one with bamboo stick penetrating the neck tissue without damaging any vital structures except facial nerve injury. Mod e of entry, the peculiarity of the foreign body, the management protocol and the outcomes of neck injury are evaluated in the three cases of this case report. Review of literature revealed that few such cases have been reported. DOI: http://dx.doi.org/10.3329/bmj.v42i1.18978 Bangladesh Med J. 2013 Jan; 42 (1): 31-33

Traumatic gunshot wound to the larynx with subsequent aspiration of the bullet

Penetrating trauma to the neck, laryngeal fracture and foreign-body aspiration are three injuries that, individually, infrequently occur in adults. Reports of penetrating neck injuries and foreign-body aspiration presenting simultaneously, have been described in the literature. The authors present the previously unreported case of a penetrating gunshot wound to the pharynx with resulting laryngeal fracture followed by aspiration of the bullet in an adult patient. In this case, appropriate treatment of the neck injuries must be prioritized along with locating and removing the aspirated foreign body.

Use of a Gum Elastic Bougie in a Penetrating Neck Trauma

The case of a patient with a zone II penetrating neck injury who was intubated successfully utilizing the gum elastic bougie (GEB) is reported. He presented at a forward operational base in Afghanistan with a shrapnel wound in his neck as well as a cough and hoarseness. There were two wounds on each side of his laryngeal cartilages. The patient's breathing rate gradually increased and labored inhalation developed while the aeromedical evacuation was delayed for tactical reasons. Subcutaneous emphysema and edema concealed the anatomical landmarks, making a cricothyrotomy unsafe, and no fiber optic devices were available on site. Intratracheal intubation was decided upon by the doctors involved. Because of the anticipated difficultly of intubation, the GEB was used from the outset. During direct laryngoscopy, edema, blood, and mucus concealed the anatomic reliefs of the larynx. The glottis was not visible. On the second attempt, "clicks" were clearly perceived and the tube was railroaded over the bougie. Finally, the patient was evacuated to an Afghan military hospital. In this report, the benefit-risk balance for the use of the GEB in penetrating neck trauma is discussed. Although the use of the GEB cannot be recommended in all cases of penetrating neck injury, it should be considered as an option. This technique is not without risk, but in very remote settings or hostile environments, especially when cricothyrotomy is not possible, it can be lifesaving.