2008/05/01 by Samuel A. Tisherman, Faran Bokhari, Bryan Collier +10
Medicine · #Trauma Management and Diagnosis #Trauma and Emergency Care Studies #Abdominal Trauma and Injuries
paper · doi:10.1097/ta.0b013e3181692116
STATEMENT OF THE PROBLEM Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent on the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds. The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The neck has been divided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common1 and can affect length of stay.2 Mortality, particularly for major vascular injuries may reach 50%.3 Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes.4 Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated. Controversy arises over management of the patient without significant symptoms. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Mandatory exploration, while seemingly safe and conservative, led to many nontherapeutic operations. This fact, along with advances in technology, such as high resolution computed tomography (CT), may eliminate the need to explore the neck to determine whether there are injuries. Also during the time that technology had been advancing, many reports have documented the safety of selective management of neck injuries that penetrate the platysma. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. This guideline was therefore initiated to examine the specific roles of mandatory exploration versus selective management based on physical examination and current imaging technologies for penetrating neck trauma. Goals of the Guideline This guideline is designed to answer the following questions regarding the management of penetrating injuries to zone II of the neck that penetrate the platysma. Is mandatory operative management or selective operative management appropriate? Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary? Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury? Is physical examination sensitive enough to rule out injuries to vascular structures or the aerodigestive tract? PROCESS The process used by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed on the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2007. Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the United States Department of Health and Human Services as follows: Class I—prospective, randomized, double-blinded study; Class II—prospective, randomized, nonblinded trial; or Class III—retrospective series, meta-analysis. An evidentiary table (Table 1) was constructed using the 112 references that were identified: Class I, 1 reference; Class II, 30 references; and Class III, 81 references. Recommendations were made on the basis of the studies included in this table. Level I recommendations, usually based on Class I data, were meant to be convincingly justifiable on scientific evidence alone. Level II recommendations, usually supported by Class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level III recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.Table 1: Penetrating Zone II Neck Trauma Evidentiary TableTable 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)Table 1: Penetrating Zone II Neck Trauma Evidentiary Table (continued)RECOMMENDATIONS Selective Workup—Operation Versus Selective Nonoperative Management Recommendations Level I: Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations. Level II: High resolution CT angiography offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available. Level III: No recommendations. Scientific Foundation Nonoperative management of penetrating neck wounds was common in the early 20th century. Based on a review of civilian experience, Fogelman and Stewart5 recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. The rationale was that a significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries.6 In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al.7 estimated the cost of a negative exploration at 1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al.8 found that neck explorations under local anesthesia, compared with general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable.9,10 Mandatory exploration gained in popularity as studies showed that clinical symptoms were not present in 0% to 23% of the cases. However, mandatory exploration was negative 53% to 60% of the time and did not identify any injuries. In addition, some of the clinically silent injuries were venous and pharyngoesophageal injuries, which did not require operative therapy.11–13 Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed,14–34 though observation for up to 48 hours may be necessary,35 depending on the use of ancillary tests. Jurkovich et al.36 compared the results of mandatory exploration (the preference of the attending surgeon) in 47 patients with a selective approach in 53 patients using 43 angiograms and 14 endoscopies. In the mandatory exploration group, the negative exploration rate was 53%. In the selective approach group, 12 injuries were found but only five patients benefited from the work up. Some studies specifically recommended that to manage penetrating neck injuries, a well-staffed teaching hospital with a trauma service and immediate availability of radiologic and endoscopic evaluations is needed.37 However, it has been shown that selective management can be safe in community hospitals with experienced surgeons.38 Evidence of chest injury does not seem to be an indication for neck exploration.39 Debate on the issue of selective management continued as Meyer et al.40 questioned this new approach of selective exploration for penetrating neck injuries. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy, and esophagography in each patient before a mandatory exploration. Forty-eight injuries were identified in 35 explorations. Of concern was the fact that five patients had six major injuries that were not identified by the preoperative testing. Thus they believed that a mandatory exploration approach was indicated. More recent studies have consistently shown that the selective approach is a safe option. In a series of 128 asymptomatic patients who were observed by Biffl et al.,41 based primarily on physical examination, only one patient had a missed injury (from an ice pick). Only 15% of these patients required adjuvant tests. Sriussadaporn et al.42 also successfully observed 17 asymptomatic patients. Only 2 of 40 patients who underwent exploration did not need the operation, though they seemed to have deep wounds. In asymptomatic patients, Nason et al.43 found that 67% underwent negative explorations. All zone II vascular injuries were symptomatic. Narrod and Moore44,45 reviewed their 10-year experience with penetrating neck trauma. In the first 6 years, mandatory exploration led to a 56% rate of negative explorations. In the next 4 years, a selective management strategy was used. Forty-one of 48 patients who underwent exploration had significant injuries,45 whereas 29 asymptomatic patients were observed without any missed injuries. Few ancillary studies were performed in this group. In a large, retrospective study from Johannesburg, South Africa, Velmahos et al.46 compared results with patients who underwent immediate surgical exploration versus constant monitoring. In the exploration group, 3% of the explorations were unnecessary; mortality was 4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%. Criteria for observation versus exploration were not clear making the interpretation of the 9% missed injury rate difficult. The only randomized trial comparing mandatory neck exploration with a selective approach based on physical examination and radiographs was performed by Golueke et al.47 in 160 patients. There was no difference in hospital stay, morbidity, or mortality. Management of transcervical gunshot wounds deserves separate consideration because of the high likelihood of major injury.48 Hirshberg et al.49 explored 41 patients with transcervical gunshot wounds. Twenty-eight had more than one zone of the neck involved. Although seven patients did not have major injuries, 34 patients had 52 major injuries to cervical structures mainly involving vessels and the upper airway. Sixteen presented with life-threatening problems. They recommended mandatory exploration. In contrast, Demetriades et al.50 found that a selective approach based on physical examination, angiography, esophagoscopy, and esophagography was safe. Helical CT angiography is the newest technology to be tested for identifying vascular injuries from penetrating neck trauma, particularly arterial injuries. Because it might also be useful for identifying or ruling out other injuries (e.g., aerodigestive tract injury), this modality is particularly intriguing as a “one stop shop” to evaluate asymptomatic patients for selective operative management. The speed and resolution of this modality continues to improve. Gracias et al.51 have already recommended that if a CT demonstrates trajectories that are remote from vital structures, the need for additional invasive studies can be eliminated. In the setting of a mandatory exploration protocol, Mazolewski et al.52 found that CT angiography, compared with operative findings, was 100% sensitive and 91% specific in 14 patients. Both Munera et al.53 and Nunez et al.54 pointed out the utility of CT angiography for identifying nonvascular soft tissue injuries, and the vascular injuries. Inaba et al.55 reviewed their experience with 106 patients who had penetrating injuries to the neck. Fifteen required urgent operation. The remainder underwent CT angiogram. Two tracheal injuries and two carotid artery injuries were identified. No injuries requiring intervention were missed. Use of CT angiography can safely decrease the number of neck explorations and, more importantly, the number of negative neck explorations.56,57 In addition, CT angiography can decrease, though not eliminate, the need for formal angiography and esophagography in some patients.56 Management of neck wounds in the military setting may be different from that in the civilian world. Prgomet et al.58 found that injuries that did not penetrate the platysma did not cause significant injuries. Forty-nine of 84 patients who underwent immediate exploration had injuries to vital structures. They also found that it was safe to close the wound primarily if it was seen within 6 hours of injury. In their experience, even extensive laryngotracheal injuries could be repaired safely.59 There is little data on selective management of penetrating neck injuries in children. Small studies60,61 suggest that a selective management strategy is safe. Diagnosis of Arterial Injury Recommendations Level I: No recommendations. Level II: CT angiography or duplex US can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck. Level III: CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed. Scientific Foundation In the era of mandatory neck exploration for penetrating trauma, there seemed to be little need for angiography, though some9 suggested that the angiogram could assist in operative planning and thereby minimize morbidity or rule out the need for exploration.62,63 Physical examination, however, seemed unreliable for ruling out arterial injury.64 Delayed pseudoaneuryms and neurologic events have been described in originally asymptomatic patients, prompting some to advocate angiography in all such patients.65 A negative arteriogram in a stable patient can rule out an arterial injury.66 North et al.67 reviewed the records of 139 stable patients with penetrating neck trauma. Patients who had at least soft signs of vascular injury (absent pulse, bruit, hematoma, or altered neurologic status) had a 30% incidence of vascular injury by angiography, whereas only 2 of 78 asymptomatic patients had injuries (one minor and one that did not affect management). Gunshot wounds were more likely than stab wounds to cause vascular injury. Similarly, Hartling et al.68 found, using angiography, that 43 patients with stab wounds to the neck and minimal symptoms had no significant injuries. Even in the 18 patients with physical findings consistent with a vascular injury, only two had significant injuries. Similarly, Rivers et al.69 questioned the value of angiography. Of 63 angiograms in 61 patients, only 6 were abnormal. Three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by arteriography in the absence of suggestive physical findings. No major arterial injuries that were missed preoperatively were discovered during exploration. Angiograms did not alter the course of management. Noyes et al.70 examined the accuracy of a selective management strategy. Arteriography and laryngoscopy/bronchoscopy were 100% accurate. In contrast, Sclafani et al.71 found that 10 of 26 patients who had positive angiograms for penetrating vascular injury to the neck had the angiogram because of Physical examination had a of and of They also found no in their results based on of injury. They suggested that proximity not be as an indication for angiography in these patients. et performed angiography for proximity or soft signs of vascular injury. Fifteen injuries were found on patients without any signs of injury were successfully observed without angiography or operation. only one patient had a significant injury that was not by physical In contrast, et found that based on the of or CT of the neck or to major vessels can be but are examine the cost of angiography, et patients with penetrating neck trauma. of the 48 patients with vascular injuries had clinical findings. Management in the other patients was not altered by the angiogram. They the cost of angiography in asymptomatic patients to be approximately Demetriades et compared physical examination and duplex US imaging with angiography in stable patients with penetrating neck injuries. Only patients had vascular injuries by and only two of these injuries needed to be The injuries were or on physical examination, but six that did not require were missed 100% for injuries, but for all duplex US 10 of injuries, including all were for an of 91% for clinically and of studies by Demetriades et included patients. Of the 160 asymptomatic patients, had injuries that did not require duplex US was sensitive for findings that required an and 100% specific for an injury. Similarly, et found that duplex US was sensitive and specific for vascular injuries both neck and trauma. The only missed injuries were two injuries that did not need repair. In a et found that US identified all 10 significant injuries in 52 patients with penetrating neck trauma. US did not identify carotid in one patient and did not two by the found in patients that duplex US had 100% and et that duplex US up two intimal flaps that were not identified on angiography. Munera et patients, who had 10 vascular injuries. There was one missed injury by CT angiography because the study actually did not the neck. They suggested that patients with or at may be treated by angiography because of the for Helical CT angiography is by to which may arterial these patients angiography. et reviewed their experience with CT angiography in patients with penetrating trauma and with and found no missed injuries, only one patient with penetrating trauma had a carotid injury at Diagnosis of Injury Recommendations Level I: No recommendations. Level II: contrast esophagography or esophagoscopy can be used to rule out an esophageal that operative repair. be because morbidity if is by more than Level III: No recommendations. Scientific Foundation The with penetrating injuries to the is that there are no findings on physical can the This is of concern and management can to significant morbidity and and with to Even gunshot wounds can be more may to of the injury can affect as injuries above the can be without whereas more injuries require neck to a deep tissue et also found that patients with injuries and on contrast studies could be observed without there was indication for exploration. All 26 patients with injuries had Of 17 patients only one developed local patients had tracheal injuries. In addition, patients with tracheal injuries have if they have esophageal Noyes et al.70 found that were and esophagoscopy was accurate. et used a strategy of esophagography by esophagoscopy if the were to identify esophageal injuries in patients who had no or minimal symptoms penetrating neck trauma. All 10 injuries in patients were identified. et found that esophagography was 100% sensitive and specific in patients. et reviewed patients with penetrating neck trauma. All patients with gunshot wounds underwent whereas patients with stab wounds were only if they had with studies were performed and injuries were identified. All were observed without contrast studies demonstrated resolution of the injury. In patients with esophageal injuries, et found that esophagography only identified of the injuries whereas esophagoscopy all injuries. et found accuracy with In patients, identified the only two injuries, but suggested an injury in patients, in negative for an of 100% and of of the Physical Recommendations Level I: No recommendations. Level II: No recommendations. Level III: physical examination using for including of the carotid is sensitive for arterial and aerodigestive tract injuries that require repair. the morbidity of missed injuries, have a for imaging Scientific Foundation reports suggested that the physical examination is unreliable to rule out a vascular injury. and found physical examination of neck and injuries a 20% negative rate and a positive and found an accuracy of physical and found that clinical signs were in 30% of patients with positive neck explorations and in of patients with negative neck their approach of mandatory exploration. More Demetriades et patients with penetrating neck injuries. patients underwent exploration for positive physical examination findings or a positive whereas asymptomatic patients were Only two of the patients required In a subsequent this demonstrated that physical examination did not any major vascular or esophageal injuries that required though minor injuries were identified by angiography of required and a selective approach based on and physical et observed asymptomatic patients without Of the 52 patients who underwent exploration based on physical examination, did not have significant injuries. Similarly, et found that only 1 of asymptomatic patients had a vascular injury by angiography. in this patient physical examination out of vascular injuries and the for angiography was et found that if patients did not have physical examination findings of arterial injury expanding or than 10 a or or a neurologic no vascular injuries were present based on angiography, duplex or clinical They observed patients for at least et found that only 2 of 30 patients who underwent exploration for hard signs of vascular injury did not have a significant injury. of asymptomatic patients underwent angiography for proximity or of Only one of these patients needed an operation. All other patients with negative physical were safely observed without et found that of patients with positive physical examination had a positive angiogram. Of the patients with negative physical only had positive but needed operations. physical had of and a negative value of Both and negative value for injuries requiring were A recent study by et in on physical examination to rule out vascular injuries to gunshot wounds of the neck. Of patients with gunshot wounds to any zone of the had positive physical findings a vascular injury, whereas 10 patients with negative physical findings were found to have injuries by angiography, physical examination a negative value of The of these findings is to because they included all zones of the neck and did not the of the injuries that were identified. or are physical findings suggestive of aerodigestive tract injuries that may require operative et reviewed the of patients with or had and had or underwent and Patients without injuries or were successfully observed without exploration. The though that to determine whether imaging to physical examination in the of patients with penetrating neck injuries was that by et patients, who did not have need for at underwent soft tissue CT of the neck and esophagography before mandatory exploration. All tracheal and carotid injuries were identified by physical Two of esophageal injuries from stab were missed by both CT and CT was than physical examination for identifying venous injuries, but of these did not require Selective management of penetrating injuries to zone II of the neck has common for asymptomatic patients. The roles of physical examination, duplex CT angiography, and the the imaging modality that the for ruling out and esophageal injuries is CT angiography. are needed to this the resolution of CT accuracy imaging studies may early of patients with neck injuries.